Jesse McDonald Page: 1

NURSING AUTONOMY IN A
MULTIDICIPLINARY PRACTICE

by

Jesse E McDonald, Jr

A thesis submitted in partial fulfillment of the

requirements for the degree of

Masters in Nursing
Module 2

University of Dundee

September 15, 2004

JESSE E MCDONALD
15161 RIO GRANDE DR
MORENO VALLEY, CA USA 92551
JESSE@RCRMCEDUCATION.COM
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AUTONOMOUS NURSING IN A
MULTIDISCIPLINARY ENVIRONMENT

INTRODUCTION:
The care of sick and injured patients is a complex and multifaceted process. It requires the
skills of a complex, multidisciplinary team. Within this framework nursing has struggled
to find its rightful place as an autonomous specialty. The fact that nursing has achieved
this autonomous role is both amazing and denied. It is amazing in light of the humble
beginning of modern nursing (the so-called Nightingale Reformed Nursing). And it is
denied by those who continue to call for equality with medicine and law as an
autonomous profession. One reason for this confusion is a lack of clear understanding of
nursing’s role as a member of the multidisciplinary team. A second factor is a
misunderstanding of what criteria constitute autonomous practice.

Nursing is the member of the team that implements the medical plan of care. One
physician described this role by saying that nurses run the show we advise (Snelgrove S &
Hughes D 2000). This is not an inferior role. Only nursing has the education, experience,
and continuous access to the patient to implement the plan of care and monitor the
ongoing results of treatment. Without this implementation the plan is simply an idea on
paper. Further, nursing occupies a position that enables it to coordinate the services of
other team members. Thus we see nursing controlling hospital bed allocation, scheduling
ancillary testing, medication administration, as well as discharge planning. When a
physician needs a particular service or task accomplished, they frequently look to nursing
to make it happen. If Kanter (Kanter R 1979) is correct that power derives from access to
resources and the ability to coordinate cooperation, than nursing enjoys a powerful place
on the multidisciplinary team.

Why the Confusion?

The confusion about nursing’s role goes back to the early post-Nightingale days. At that
time physicians largely controlled the hospitals including the hiring and firing of nurses
and the setting of nursing policy (Godden J & Forsyth S 2000). Florence Nightingale
distanced herself from the conflict and tension inherent in nursing’s effort to find it’s own
place in the care team. An outgrowth of these roots led to the widely accepted myth that
physicians cure and nurses care. This myth, alone, has done much to diminish the
perception of nursing’s real role and function.
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In 2003 Gerrish et al interviewed 18 educators in Master level programs in nursing. They

were looking for the common essential core values these educators held for nurses.
Recurrent themes were focused on the power of the nurse, blurred boundaries between
nursing and medicine, and relations with other professionals. Conspicuously absent was a
focus on caring. As they noted, the supposed centrality of emotion work and caring is
one of nursing's myths. Holistic emotion work is a secondary consideration in modern
health care and claiming such work as a basis for professional jurisdiction may not be an
effective way of achieving professional status (Gerrish K, McManus M, & Ashworth P
2003) .

Central to this myth is the self-assertion by nursing that it is the profession that cares
ABOUT the patient. There is no mandate for nursing in this, since it is clear that other
professions also care about the patient. Physicians care deeply about the patient and the
outcome of patient care, as do respiratory therapists, housekeepers, and the patient’s
family. Two problems that arise from focusing on caring about the patient are that nurses
lose sight of who their clients really are and second, they lose their grip on what the real
nursing mandate is: caring for the patient.

As Gerrish et al (2003) noted, “the work that nurses now undertake caring FOR patients
makes it increasingly difficult to engage in the kind of work in which they also care
ABOUT them; a little more realism may make a more sustainable professional future”.
This does not mean that modern nursing is devoid of human feeling or that nurses should
care less about their patients. Rather, it means that caring about the patient must find its
expression in caring for the patient.

NURSING’S MANDATE:
Nursing’s mandate provides the reason for our existence and delineates the position nurses
hold on the multidisciplinary team. There is a role that nursing plays that no other
member of the team can fill. That mandate can be simply stated as the implementation,
management, and monitoring of the therapeutic plan of care. This is caring for the patient
in a way that no other member of the team can. Only nursing has the combination of
education, resources, and continuous contact with the patient that is necessary to ensure
the medical plan of care is implemented, monitored and modified as necessary to reach the
discharge goals for each patient.

Before a meaningful discussion of nursing autonomy is possible, it is important to

understand this mandate. Knowing the role nursing fills is necessary in order to recognize
who nursing’s clients really are. Professional power and autonomy are always exercised
for the service of the client. The legal and professional relationships with the client
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provide the framework within which autonomy operates. To speak of personal autonomy
without reference to these complex relationships, within which a profession operates, is to
speak of anarchy.

Yet this is often the case when nurses discuss autonomy. O’Connell and Warelow
(O'Connell B & Warelow P 2001) cite as evidence of the “questionable” autonomy or
even the lack of professional autonomy the situations where nurses felt that they could
not influence the medical care of the patient or where the physician could over ride a
nursing decision. There was not even recognition that the medical role and nursing role
are complementary. The physician did not order the treatment the nurse decided was
appropriate and that was enough to create a sense of powerlessness in the nurse.

These are not isolated views and reflect confusion over the exercise of clinical autonomy
and power. Keenan (Keenan J 1999) acknowledged the difficulty of defining autonomy
and reviewed various uses and conditions for its application. She draws the distinction
between personal and occupational autonomy and discusses some of the requirements for
being autonomous. However, in the end she states that, given the nursing’s historical lack
of power vis a vis the medical profession, full professional status is probably not possible.
Fortunately, this bleak position is not only untrue but nurses around the world are
actively practicing full professional autonomy.

CLINICAL AUTONOMY:
A solution to this apparent paradox is found in Cash’s (Cash K 2001) concept of clinical
autonomy in relationship to contractual space. He argues that all professions operate
within boundaries and use procedures that are generally accepted by the discipline. The
real question is not whether there are boundaries but who is setting and regulating them.
In the United States, as in many other countries, nurses supervise nurses. Nursing
Administrators write the policies and procedures that control individual nursing practice
in a given institution? Nurses sit on the regulatory boards that govern the licensing and
legal practice of nursing. This subordination of individual autonomy to occupational
autonomy compares very favorably to the experience of general practice physicians in the
United Kingdom who were regulated and administratively controlled by government
regulations and professional practice groups (Harrison S and Dowswell G 2002).

This was illustrated in the United States by the response to a very popular television
program titled “ER”. This program portrayed nursing in a very subservient role which
drew an open letter to the producer from the president of the Emergency Nursing
Association (Robinson K 2004). After pointing out that nursing is an independent
profession that is not controlled by physicians and is not obligated to carry out
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questionable or erroneous orders, she goes on to note that physicians do not hire, fire,
supervise, or discipline nurses. Nurses are “hired by the hospital to care for patients while
physicians only have admitting privileges”. Robinson then notes the following statistics.
In the United States, nurses hold 32.9% of the Director of Emergency Services positions
while physicians hold 35.4%. When it comes to Emergency Department managers and
assistant managers, 73.9% are nurses compared to less than 1% who are physicians.
Robinson points out that “without nurses there is no health care”.

In modern health care institutions nursing is controlled and regulated by a department of

nursing. Nursing is represented at the executive level on operational boards and nurses
write the nursing procedures and policies. The Chief Executive Officer of a large regional
hospital recently circulated an open letter to all the hospital staff in which he stated, “We
can not accept any reluctance to question an action or order regarding patient care. All
members of the team are to accept responsibility - if you see a problem, you own it until it
is resolved or it has been appropriately passed on to someone who can. All personnel are
absolutely obligated to express concern about any potentially unsafe order or care.
Medical Students and Residents should recognize that our nurses spend the most time
with our patients. Their observations and experiences are a major resource, which should
be cherished and accessed” (Bagley D 2004).

Nursing Power:
It is axiomatic that if nursing is to be autonomous it must exercise power. How then is
that power acquired and to what extent can it be exercised? Power, in the sense of having
the authority to accomplish the work, is part of being a professional. This professional
power is a power to accomplish; it is a Power TO as compared to a Power AGAINST or
a Power OVER. This power as mastery (rather than a power over others) is a
fundamental part of nursing practice. It is displayed as the ability to mobilize resources
and evolves from two capacities: 1) Access to resources, information, and support and 2)
the ability to get cooperation (Ellefsen B & Hamilton G 2000). Wherever nursing
exercises this power it is recognized and rewarded with full team membership.

This recognition is often more personal than corporate. The ability of nursing to
recognize and utilize its power for the benefit of common goals determines whether it will
be recognized as powerful and autonomous. A study of Australian general duty and
critical care nurses (Chaboyer W and Patterson E 2001) noted that collaborative
relationships cannot evolve unless individuals value and respect each other’s competencies.
They must also view themselves as a team with common goals. In this study critical care
nurses were seen as more collaborative with the biomedical model, engaged in more
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teamwork, and participated in medical conferences. They were also more often accepted
as colleagues by the medical staff.

Nurses are not forced to practice autonomously. Physicians and other team members will
consciously or unconsciously compensate for poor nursing performance. Managers may
assign these dependant nurses less challenging patients. And there may not be an
immediate financial penalty for less professional performance. The attitude of these
dependant nurses may be summed up by a graduate nurse who stated that it was the
physician’s responsibility to look up the pathology and lab reports: ‘It’s not my job to
ring him up and tell him the patient has a high potassium’ (Manias E & Aitken R 2004).
It is this attitude that limits autonomous practice. The professional nurse will aggressively
seek out all relevant information about the patient and ensure that significant results are
provided to the physician, or other appropriate team members, in a timely manner.

Confusion about the autonomous nursing practice can lead to serious errors. Manias and
Aitken (2004) report the comments from a graduate nurse who stated that a physician had
ordered a medication every six hours but she chose to give it every four hours ‘because I
knew other patients who got it every four hours and I knew it would not be effective
every six hours’. This is not autonomous nursing. This is a medical decision that only the
physician is qualified to make. The autonomous nursing response would be to discuss any
ineffectiveness with the physician so that the medication can be adjusted properly without
putting the patient at risk for toxicity or adverse reactions. This episode does raise the
question about who really is the nursing client. Autonomous practice can only occur
when both nursing practice and nursing clients are clearly identified.

The Nursing Client:

The obvious client appears to be the patient. The nurse referred to above would certainly
say she was working for the patient. However, in today’s modern health care system the
patient seldom contracts directly for nursing services. Most patients come into contact
with nurses as a result of a referral (admission) from a physician. The physician orders the
treatment plan and refers the patient to the nurse, either directly or by way of a hospital
admission, to receive this care. Thus the physician is not a competitor with nurses. The
physician is one of our main clients. The patient is now in the role of a beneficiary. This
does not in any way diminish the work or responsibility of the nurse to the patient. It
broadens the nursing role to include the active participation, along with the physician, to
ensure that the patient receives the maximum benefit from the medical plan. And it
places the nurse in the role of coordinating the various ancillary services and
communicating among the various providers so that the necessary flexibility and
adjustments to the plan can be expedited.
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It is impossible to practice autonomously without using the common knowledge base.

Nurses must be competent in using the terms of the biomedical model in describing
assessments and changes in the patient’s condition. This will not “make doctors out of
nurses”, as some nursing leaders fear (Sullivan E 2002). There is a clear and distinct
difference in the knowledge, education, and experience between physicians and nurses. It
means using the common data in a distinctly nursing way. It means being competent in
the administration and usage of various medications and treatments. It means knowing
the fundamental pathophysiology of the patient’s disease, the expected outcome of the
medical plan, the common adverse effects and how to recognize them, and how to
communicate effectively with those responsible for the medical management.

An Australian study of 363 graduate nurses who took a pharmacology test demonstrated a
collective mean score of 56% (Manias E & Aitken R 2004). Another group of nurses was
able to record an electrocardiogram but were unable to understand it. If nurses are to be
respected team members we must have a clear working knowledge of our craft. This
requires more than the legal requirement of a few hours of continuing education for
license renewal. It means recognizing gaps in our knowledge (for example, the use of a
new drug) and aggressively seeking out the knowledge required to use it effectively.

In the emergency department practice autonomous nurses make sure the necessary patient
assessments are documented and significant findings are communicated to the managing
physician. By assessing lung sounds and pulse oximeter readings the nurse can discuss the
patient’s dyspnea more intelligently with the physician. By understanding the significance
of common pathophysiology the nurse can broaden the assessment to include symptoms
of other problems that must be ruled out or included with the management. And the
nurse can be sure the required follow up is done, that the physician receives timely and
accurate information about how the plan of care is proceeding, and that important
information moves properly between the patient, the physician, and the associated
departments. The autonomous nurse becomes the manager of care, the center of all the
therapeutic activities, and exercises the tremendous power that comes with being able to
marshal resources, access data, and facilitate outcomes. The autonomous nurse is truly an
outcomes manager. And all of this is done with the kindness, caring, and human touch
that have always defined nursing.

Summary:
The autonomous practice of nursing in a multidisciplinary team requires the clear
understanding of the nursing mandate as well as the role other team members. Acting as
the center of the team, and accessing the resources required to implement the medical
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treatment plan provides one pillar of professional nurse’s power. The other pillar is the
coordination and cooperation that only nursing is best positioned to accomplish. The
truly professional nurse is the “go to” person on the team. The team member others
approach to ensure the successful implementation of the common goals.

It is important to recognize that this clinical power and autonomy are corporate and
occupationally centered. It is not the power of any individual nurse to do whatever they
may think is the best action. It is the power and autonomy of working within an
organized and legally recognized profession to achieve the common goals of the
multidisciplinary team. It is the power of cooperation and resource management that
makes the nurse an indispensable member of the health care team.

This professional environment provides the wide diversity of practice available to the
modern nurse. Today’s nurse can be an administrator, a clinical practitioner, business
manager, or an educator. Nurses sit on the boards that govern the operation of hospitals
and clinics; they operate their own professional practice associations (such as the
American Association of Critical Care Nurses) that set the standards of best practice for
their specialties. And both government and private accreditation organizations as
recognize them as expert resources on the clinical practice of nursing.
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References

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message from the Chief Executive Officer to All Staff). 7-29-0004.
Ref Type: Personal Communication

Cash K, 2001. Clinical Autonomy and contractual space. Nursing Philosophy, vol. 2, pp.
36-41.

Chaboyer W and Patterson E, 2001. Australian Hospial Generalist and Critical Care
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Ellefsen B & Hamilton G, 2000. Empowered Nurses? Nurses in Norway and the USA
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O'Connell B & Warelow P, 2001. Challenges of measuring and linking patient outcomes
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Robinson K. 2004. Open Letter to ER Producers. Journal of Emergency Nursing 30, 6-7.
Ref Type: Generic

Snelgrove S & Hughes D, 2000. Interprofessional relations between doctors and nurses:
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Sullivan E, 2002. In a Woman's World. Reflections on Nursing Leadership no. 3rd Quarter,
pp. 10-17.