I’ve been thinking about autonomy lately; the right to self-govern, the state of existing separately and independently of others, or so Merriam-Webster tells me.

Are nurses autonomous?

The statement, “Nursing is an autonomous profession,” isn’t new to me, but lately, it’s causing me pause. Each varied source I’ve recently run across argues the same point: Nurses don’t report to doctors. Nurses report to other nurses.

While this is technically true, it seems one-dimensional, and a conversation with a classmate proved it pretty irrelevant: “Name a hospital model that functions without an ordering, diagnosing physician,*” she charged. Mine was an empty hunt. On the flip-side, she asked, “Could a hospital function without nurses?” After some thought, and some skepticism, I had to say yes.

A hospital could exist without nurses. Physicians could perform all physician-level tasks, and all the tasks of nurses, too. Could a physician place an IV or keep track of vital signs? Pull up a patient? Yes, and in many countries, and some lucky ICUs, most physicians do. Physicians have the legal ability to perform every nursing task, they just don’t.

A bedside nurse, on the other hand, could not replace a physician. I could not diagnose CHF, or cancer. Legally, I could not perform a thoracentesis, or obtain a consent. I don’t really want to do any of these things, much like most physicians don’t want to do nursing things, but the crucial difference is that I cannot, making my presence negotiable.

At all?

So what are we here for? Why are we around? How are we even remotely autonomous? We exist, in the hospital, anyway, because physicians exist; I’d have no reason for my place at the bedside without the existence of a doctor. But, under my friend’s model, one that seems lurking, he’d be fine without the existence of me.

Or would he? It took me a lot of thought, and a lot of conversation to finally hypothesize where nursing autonomy might lie. Nursing autonomy lies in our constant presence. With our constant presence, we provide surveillance for our patients, real-time information to our leaders, and translatable navigation to colleagues, patients, & public in unique and relevant ways.

Simply by the nature of our jobs, we have ownership of presence for our patients. This presence hails back to Florence Nightingale’s famous lamp routine, giving us autonomy that physicians cannot have — they, in fact, rely on us for this. We are constantly present, or should be, and, as a wise professor-mentor of mine has been known to say, our ability to survey and protect our patients, acts much like an extremely detailed security operation – we watch, we report, and we respond – because we are expected to see.

While most directions for surveillance are given to us by physicians (neuro checks every two hours, watch for a heart rate greater than 60, etc), many hail from our nursing knowledge. This knowledge, which we mistakenly label, “sense,” secures our irreplaceable presence at the bedside. Coupled with our ubiquity, we see and report the tiny, imperceptible changes in our patients conditions that other providers simply don’t have access to. This unique relevancy is what we must focus on when collaborating with our health care teams, in our purposeful shift-by-shift description of care to our patients, and in our proactive discussion of care to the public.

Without this purposeful nursing presence, patients suffer, and it is here that our care breaks down; without our constant presence, we lose our ability to watch effectively, and we give inadequate surveillance and troubled care. How could an alarm system be expected to prevent a breach without a fully functioning fleet of technology? On the opposite side, when we are given tools to function as intended, our surveillance translates not only into protection, but into prevention, education, and navigation for, and of, our patients.

Does it matter?

Operationally, sure, we’re autonomous. We are yelled at by our nurse managers when we’ve made a mistake, we report to the nursing supervisor when another staff member (doctor included) wrongs us, and we get paid by “Nursing.” And we do a lot more than just watch out for patients, as my tired feet, back, and fingers can attest. But clinically, no, we’re not really autonomous, not even many of us with prescribing powers.

And this is where I’ve landed for now. Wondering to myself: Should we seek autonomy, or should we seek relevance? We may not carry oil lamps anymore, but oddly enough, I’m starting to think our modern-day answers might lie somewhere within Florence’s old ritual.

*Partly for the sake of my literary soul, but mostly for my inner policy skeptic, I’m sticking with the term physician to describe all prescribing providers. I know that many others exist, and I support their varying paths to autonomy, too.