This is a complicated topic, aspects of which are rooted in gender, class, and politics. For substantive change to occur the regulations regarding nursing practice (those that are "granted/allowed/permitted') need to alter.

In the USA due to shortage of doctors especially in rural areas, some state boards are allowing nurses to receiving additional course work and training and elevate them to Nurse Practitioner status. Then they can prescribe medications like MD doctors and perform almost all of the duties of a doctor. This is an avenue for aspiring nurses and would give them more autonomy. As has been pointed out bias of various forms still exist in this field.

Cheryl A Smith-Miller Really, it's a complicated issue entangled in the triangle you mentioned. Hoping for the better regulation from nurse leaders and organization that focuses more towards our nurses in clinical field.

Srini Vasan The scenario in USA can be much aspiring for the nurses working there which will help them gain more autonomy in practice, but still nurses are utilized as a replacement for the doctors or helping out their burden instead of experimenting their own scope of care that would differentiate nursing as different profession with their own value and need for the patients. We hope nurses could explore more in themselves rather than inclining towards the helping profession for es@tablishing others.

Nursing is an autonomous profession, but it seems nurses are forgetting about their autonomy. If nurses strictly adhere to utilizing nursing theory and nursing care plan during their practice no body from any other profession can involve in their duties. Who is having the knowledge of these two body of knowledge apart from nurses.

Making clinically credible researches and utilizing the findings of those researches is another way nursing profession can excell mong all the healthcare professionals, since nurses interact with patients more than members of any other profession.

I have the unusual position of being a nurse-physician-educator so I may see things a bit differently. As mentioned, nurses can practice independently. but they have to practice nursing. To practice medicine is altogether different. I can think of many venues where nurses practice without "supervision" or oversight but their practice is limited to nursing. I think what is desired is to practice a form of medicine which requires a much larger knowledge base. Please, separate the Idea of knowledge from the idea of judgement. Most nurses I know have very good judgment but not a large knowledge base. Nursing, at its core, is the treatment of a person's response to an actual or potential disease or injury. Medicine is diagnosis and treatment of the disease itself. Medicine is not just nursing on steriods but undamentally different in both theory adn practice.

Very impressive answer by Bruce St. Amour that purely separates nursing profession from the huge medical body and stresses on the innovation required in the field of nursing care to improve it for the better comfort of care receivers. To improve in this, we need to explore inside nursing care and find the scopes utilizing prevalent nursing theories and process and even revise them according to the need as mentioned by Yahaya Jafaru

Nurses already have some leverage of autonomy. In a hospital setting, I don't think autonomy equates to quality patient outcomes. I find a collaborative effort amongst all staff equates to good patient outcomes. That doesn't mean cohesiveness by doing whatever the doctor tells you is the best avenue to take. But it often turns into that.

Nurses are patient advocates. Meaning it is our job to protect the patient's wishes at all times. It is veto power of what happens to our patients. However; I find that many nurses are nervous to exercise their judgment during critical times for political reasons.

It is admittedly hard to stand up to physicians when needed. I can think of two instances in my career where I have utilized this power. There was a bone marrow biopsy and a surgical amputation. Both seemed not necessary in my judgment. I did not say this to the patient. The patients asked legitimate questions that they did not get answered to their liking. I intervened before each procedure and stated the patient is refusing the procedure, because that is literally what they said in their own words to me. Both times the MD were reasonably upset with me. However; I did not care. I was doing the right thing. In one of the instances my manager was pleased with my actions. Therefore, the political reasons for not wanting to intervene when needed.

I agree with Bruce St. Amour . Nursing to me is adaptive. Nurses assist patients to recover from illness by health teaching, following treatment protocols in hospitals and providing the emotional support often needed to recover. I am not sure what autonomy entails. Nurses are not given the education to diagnosis, but nurses can have businesses that provide nursing care. There are constantly new positions requiring extra education available for nurses who do not want to provide traditional nursing care-nurse legal consultant, nurse ethicist, advanced

nurse practitioner, nurse educator to mention a few. All that I can say is that I am responsible for my care and consider myself autonomous even though I follow MD orders. It is my judgement that justifies my actions, not the MD.

brigid

Nursing is purely a profession motivated towards the care of individuals according to their needs for which they can consider themselves autonomous as mentioned by Bruce St. Amour . I may be wrong for all contexts and all latitudes of world, but talking about the situation in developing countries, from the infrastructure to the articles provided by the management in the hospital setting are not supporting or focusing the importance of nursing care but only towards curing the disease where the role of nurses are more inclined towards just carrying out the orders without their autonomous decision where nursing theory, care plan seems extravagant. With time, things are improving and we just hope it to be better with the broadening on the scope of nursing..

I think it is important to keep in mind that even in the context of taking orders from physicians, nurses have great effect. Studies have shown that increased nursing satisfaction has effect not only on nursing issues such as turnover and burnout but on patient issues including increased quality of care and decreased mortality rate. [McHugh M, Ma C (2014) Wage, Work Environment, and Staffing: Effects on Nurse Outcomes. Policy Polit Nurs Pract. 2014 ; 15(0): 72–80. doi:10.1177/1527154414546868, Aiken L, Clarke S, Sloane D, Lake E, Cheney (2008) Effects of Hospital Care Environment on Patient Mortality and Nurse Outcomes. J Nurs Adm. 2008 May ; 38(5): 223–229.]

Doctors are taught to be nice, communicate well and always ask "Why." They are not taught to really understand people, their lives or their motivations. Is it possible that increasing the scope of nursing practice would decrease impact of nursing practice?

Research has shown that when nurses manage Congestive Heart Failure patients that they do better. MD's are constrained by time so it is difficult to provide the time for extended teaching and monitoring that a nurse can provide more economically.

brigid

Brigid : I'm convinced nurses should not replace physicians because of economic or time-schedule matters. We got a professional identity which allow us to care with paying attention to all what define the patient : his global situation, purposes, life goals, illness personal meaning,... Therefore, our holistic approach should not be used to fulfill some gap (with the great risk of loosing what nursing really means) in patient accompaniment but should be used to build a partnership with the patient and all others healthcare professionals. I think that our way to get a trustworthy privileged relationship with the patient (by our nursing skills) and the other HCPs (by our biomedical knowledge) is the key to improve public health, particularly for chronic illness management.

Main message : Nurses are medical team allies, not substitutes.

Nurses being professionals, they must claim their freedom of choice in contexts relevant to them. Clearly the ideas proposed must be supported by scientific literature. In Italy the figure of the doctor is still strong, but in my department the nurses through their experience express their opinion and the doctor recognizing them the knowledge of the patients, he trusts. A personal opinion, I would be in favor of departments with nursing management, if only there were the necessary personnel.

Dear Jehan Seret I probably phrased my comment badly, but being able to provide quality, best evidence practice care is a reason for healthcare associations and government to pay nurses to provide a service. Nurses are more affordable to the system. Why is it wrong to use that as a bargaining chip to increase nursings' presence. Nurses can not demonstrate autonomy and mastery if they are not given an opportunity. I am a cardiac nurse, so I used Congestive heart failure. Nurses make fabulous disease managers, nurse midwives and educators, but they can not get that opportunity if the stakeholders do not believe that they are capable. It is that success that nurses can build on and widen their reach.

brigid

Dear Giovanni Napoli , I have worked on a nurse lead unit years ago. It was fabulous because nurses were recognized for their contribution to the patient's

recovery. It was an open heart and cardiac surgery unit. But part of the success was the faith the patients had in the nurses to solve problems and provide care.

Sadly, Canadian medicine is not what I used to remember based on my sister's family.

brigid

@brigid I would be very curious to know the dynamics of a nursing department, I think that despite the difficulties it is something incredibly stimulating!

Dear Giovanni Napoli ,

It was a thirty bed surgical unit with 4 step down critical care beds. We received fem-popliteal bypass patients and aorta bifemoral patients from post-op recovery unit on average of 2-4 hours after surgery. We received open heart patients with chest tubes 18-48 hours after surgery. On dayshift there was a medication nurse and each nurse had 6-7 patients. On night shift the ratio was 1 nurse to 12-14 patients with one nursing aide. Doctors did not berate the nurses, they were supportive and willing to teach. We had a Clinical Nurse Specialist that pulled chest tubes and clipped pacer wires. She also encouraged the nurses to expand their knowledge base. The patients were encouraged to walk independently in the halls with their families. They were expected to learn and perform tasks-chair exercises, use of incentive spirometers, moderation of pain medication and diet modifications. When possible patients were not approved for surgery unless they had stopped smoking, drinking and if necessary lost some weight. They were also expected to have their financial affairs in order so there were no distractions to the healing process. As nurses became a part of the patient's family because we were a vital part of the recovery. The joy of contributing to actively participating patients made Hamilton General a fond memory some 30 years later.

brigid

@brigid At moment in Italy it is very difficult for many reasons, both for historical reasons and for economic reasons. The nursing profession especially in the last decades has acquired the legal recognition of its autonomy and has been a big step. Now we hope for a better future, taking organizations like those where you worked will be essential!

Brigid Conroy thank you to shared your experience!

Dear Giovanni Napoli

One of the best resources that American nurses have is the American Association of Critical Care Nurses (AACN). They provide a lot of education and a forum where nurses can network. Good Luck, brigid

Dear Brigid Conroy ,

Yes you're definitively true when you say that without being able to show how nurses may affect care, situation won't evolve. And I'm truly convinced that nurses are wonderful caregivers as you described. My comment and yours are not mutually exclusive. Nevertheless, I'm convinced nurses have a great impact by their approach and that's why I raise against voices who only see nurses as a cheap solution to replace physicians.

By the way, another point is nursing sciences research. This a a great opportunity to show clinical impact of our interventions. In Belgium, research begins to be deeper studied in bachelor degree but we are far away from USA level. For instance, we haven't yet a MSN and students are forced to enroll in a MPH to get a mastery and develop research skills.

I wish to everyone a nice day,

Dear Jehan Seret

I am a diploma graduate who is taking my BSN tot bridge with a MSN in education. The research aspect is phenomenal, but it is also in the hands of the learner because I see peers who are graduating as nurse practitioners at varying levels of competency. They see themselves as marketable in the healthcare field by employers (doctor groups and medical facilities) because of cost. That is often a determining factor in medicine in the US. It is one of the reasons that rural America has poor healthcare access., not just inner cities where poverty and job insecurity keep patients from seeking healthcare until it is almost too late. THIS is definitely a different topic but it is connected to how and where nurses can create a credible niche. American Government policy planning put money into nursing education to encourage nurses to be "cheaper and more accessible" options to communities.

brigid

Good discussion .. following

Dear Brigid Conroy

Well that's for me a problem. I'm certainly utopian but I wish nurses could be recognized for their skills and what they bring to patients first and how this expertise can be rooted in the healthcare system with its economic and political reality. Nevertheless as you describe, it's completely the reverse... Sad but let's not be discouraged and let's try to care as best as possible :-)

Nice day to everyone

Dear Jehan Seret

I choose to believe that anyway nursing can be valuable to communities means that nursing is following its passion and mandate.

brigid

Nurses should evolve the culture of the profession with a focus on empowerment and civil, positive communication. A strong support of each other is essential. Only then, will the discipline progress.

Good discussion. Nurses need to know and work within their scope of practice. This will prevent dependency on doctors and being taken as substitutes.

Nursing is an autonomous profession, if the nurses using theoretical support and nursing care plan during their practice no body from any other profession can involve in their duties. But it's very important cooperation with other's professional and promote the best practices with the clients

Maria Lourdes Souza you make a valuable point. However, at least in the United States, nurses have practice boundaries for providing care. Usually that requires a doctor authorize the need for skilled nursing care (to be compensated) and possibly for treatments (medicated dressings as an example). Yes nurses have some autonomy. In a perfect world, I would work in a nurse-led clinic for patients with CHF and COPD. Both conditions benefit from close monitoring that a nurse is well qualified to provide but which governments, insurance and health management organizations are not necessarily willing to compensate insurance for. An important issue when so many people can not afford healthcare. There are other chronic illnesses and patient populations that would benefit from nursing clinics.

brigid

As an Advanced Nurse Practitioner, who is supposed to be autonomous, it can prove difficult at times when nurses own managers (also nurses who may not have these enhanced clinical skills) and bureaucracy stifles this. My experience is that there are systems in place which do not allow for nurses to exercise their autonomy, insistence on GP/Dr referrals to other services, despite the ANP/nurse attending the assessment and making the decision as well as having the support of the medic.

I have always advocated that nurses make their decisions which are underpinned by best practice (in whichever form that comes) and policy as I have encountered too many nurses deferring to other nurses (with equal or less experience but stronger personality -sometimes) and care staff particularly in aged care facilities. They are almost afraid to make a decision, it can be frustrating and sets the profession back and certainly does not promote autonomy.

Dear Gayle Henry

I think that timidity is a serious problem and obstacle to autonomy. Nurses are socialized to follow in line more than to take a stand. I think that nurses should be socialized better to be assertive and patient centric.

brigid

Absolutely Brigid,

They also need systemic back up such as from managers, medics and peers. There is a degree of fear of being left out on your own with your decision and no support particularly in the litigious environment that is evolving.