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Nurse Leaders' Role in Promoting Autonomy and Accountability

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   February 16, 2010

Nursing issues have been in the news in the last week and not all of them have been good. First, AMN Healthcare released a survey that found nearly half of the nurses who responded want to make a career change in the next three years, and more than a third said they were dissatisfied with their job.

Then there was a piece in The New York Times' "Well" blog by Theresa Brown, RN, about the disturbing prevalence of bullying in nursing. And finally—some good news—Texas whistleblower Anne Mitchell, RN, (whose case I wrote about last week) was acquitted of all changes.

A thread runs through these stories: the lack of autonomy in nursing.

Brown quotes nurse researchers Cheryl Woelfle and Ruth McCaffrey's article "Nurse on Nurse" to speculate why nurses attack their own. "Nurses often lack autonomy, accountability, and control over their profession," they write. "This can often result in displaced and self-destructive aggression within the oppressed group."

More than 40% of the nurses in the AMN Healthcare survey were not satisfied in their positions, which may be due to a lack of control over the things that matter to them in their jobs. Mitchell lacked autonomy in her hospital to do something about a physician she perceived as unsafe, so she went to the Texas Medical Board as her only option.

Employees are happier where they have a degree of autonomy over their jobs. Successful organizations work to give their nurses as much autonomy as possible.

Eileen Dohman, vice president of nursing at Mary Washington Hospital in Fredericksburg, VA, says nurse leaders' must create an environment where nurses have autonomy—and are held accountable—for their behavior and practice.

"My responsibility is the environment that nurses practice in," says Dohmann. "That's my job: To create, reinforce, and ensure that nurses have the environment they need to safely practice."

Dohmann is accountable for all the patient care that happens in the building but she doesn't provide any of that care. She sees her role as being an advocate for the nurses and to provide an environment where nurses are in control of what happens to them. That doesn't mean nurses always get what they want. Dohmann cites the example of productivity. Mary Washington Hospital has emphasized nurse-to-patient ratios and productivity targets. Dohmann has created an environment where nurses understand their parameters and what they have to work with to provide care.

"My job is to help them understand; it's not necessarily my job to help them like it," says Dohmann. "But my job is to help them understand and then give them the autonomy. I say to my nurses all the time, 'keep it legal and keep it safe. Those are the rules. So figure it out.' Nurses at the bedside in our hospital don't want me making decisions about how they practice nursing at the bedside. I don't do it. They do it. I see my job is letting them know what the confines are that they have to live within, and the rest of my job is making sure that I get any barriers out of the way so they can do what they need to do."

Nurses treating one another poorly is nothing new. Dohmann says nurse leaders play a huge role in creating the environment that does not allow bullying. Leaders have to set expectations and hold people to those expectations.

"When you talk about behaviors and how people feel and accountability and autonomy, you have to give people permission to be accountable and autonomous," Dohmann says. "People don't feel autonomous unless you create an environment and give them permission to feel that way."

Nursing leaders must cultivate an environment where nurses can tell them what is working and what is not.

"I want people to tell me what's not going well. I can't advocate for you if you don't tell me what's going on," says Dohmann. "We have to be willing to listen and we have to be willing to hear. More importantly, we have to be willing to do something about what we hear."

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Rebecca Hendren is a senior managing editor at HCPro, Inc. in Danvers, MA. She edits and manages The Leaders' Lounge blog for nurse managers. Email her at

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