Some Thoughts on “Independent” Nursing Practice

Over at Nurse Story, Terri Schmitt poses a question:

Being the rabblerousing heretical feminist that I am, I have always sought to think of nursing as part of the medical ‘team’ where all professionals provide input to build the best care of the patient. I am beginning to wonder if my pie-in-the sky view and push to have nurses see themselves as independent professionals with a unique body of knowledge is accurate?

In one of the health systems that I interface with nurses can no longer document that they held a patient’s medications based on ‘nursing judgment’. Such an instance might be when a patient had hypotension from pain medication and thus the morning anti-hypertensive is held. Instead, they need an order from a physician to hold such medication. Further, something like ‘Tylenol’ on a patient’s medication record ordered for fever could not be administered by the nurse for a headache if the patient requested it because that would be ‘practicing medicine without a license’.  A nurse cannot order a social services consult, flush a urinary catheter should it become clogged, refer a patient for diabetes education, etc., etc., without an order from the supervising physician. Although we have been trained to recognize these things, we carry an independent license, sit for an examination to obtain that license, and have had years of education. Perhaps nurses really cannot do any of these things without a supervising physician to tell them?

Physicians, are critical components of the health care team there is no doubt, but why send a nurse to school and give him/her an independent license, scope of practice, and make them answerable to a board of nursing but then limit their usefulness? [emphasis mine]

It’s a good question and one I have pondered a lot, usually in the context of finding a work-around for physician obtuseness, or contemplating some idiocy from hospital administration.

First thought: sometimes pie-in-the-sky lets us think about possibilities, rather than limitations.

Next thought: the quick and easy answer is that nursing usefulness depends on where and how you practice. Institutional culture counts for much, especially when hospital administrators view nurses as a human resource problem to be “managed” and not professionals capable of independent judgement. (I suspect the institution mentioned by Terri has a particularly authoritarian workplace culture.) In most hospitals in Ontario, there are medical directives in place: formal documents which let nurses, using nursing judgement, to perform acts traditionally reserved to physicians. So in the Emergency Department, I can order x-rays and blood tests, give medications, defibrillate and so on, all without a physician order. Jurisdiction is important. In Ontario, for example, a nurse would be disciplined by the College of Nurses of Ontario, our professional regulatory body, for not holding that anti-hypertensive — and I don’t think I have ever asked for physician approval to flush a catheter, or to refer a patient to social work, diabetes education or home care. We can pronounce death, write DNR orders, and in certain circumstances, even start IVs without a physician order.

So well and good. The long and complicated answer: there is a dichotomy between the expectations of nursing as professionals and actual practice; it comes down to whether nurses are professionals in the same sense that physicians (among many others) are. I’m sceptical. In this case the word  “professional” conjures words like “independent judgement” and “autonomy”. It is somewhat difficult to imagine, except in some limited and particular circumstances, where nurses actually engage in independent judgement, decision-making and autonomy in the same way as physicians. We defer not only to physician orders, directives and judgement (which often see fit to determine and define practices clearly within the expertise of nurses), but also hospital policies and procedures and government regulation of our competencies. And as I have often argued, nurses do it to themselves. The culture of nursing hinders. We are resistant to change; we acquiesce all to readily to “superior judgement”; we don’t question why physicians and (increasingly) other health care professionals can write “orders”, and nurses can’t; we often refuse to learn new skill sets that would enhance our practice; we don’t push the envelope. All in all, it’s a picture where nurses are theoretically are professionals in the fullest sense, but practically we fall somewhat below the mark.

Last thought. I will speak the ultimate heresy: is it possible that the push for nurse practitioners as “advanced practitioners” was in the end damaging for the nursing profession as a whole? It consumed the energies of nurses’ associations for decades, lobbying governments and bureaucrats — and continues to do so —  so instead of arguing for advancing competencies and standards for all nurses, we focused on the independent practice and judgement of the few. The rest of us were left behind, even as other allied health professionals with comparable levels of education were granted authority to perform acts traditionally reserved for physicians. Was it worth it? Some days I am not sure. Terri mentions the difficulty and constraints in establishing nurse-led diabetic foot clinics — an area well within nursing scope of practice. Lobbying for nurses to do this sort of service independently — and there are plenty of other examples — and without direct physician supervision (which really represents a sort of unnecessary duplication) might have been more useful for both the profession and our patients.