How Intensive Care Unit Nurses Conceive of Personal and Professional Risk when Exercising Clinical Autonomy

Background: Nurses are often encouraged to work to their fullest potential, including exercising clinical autonomy--a factor known to decrease morbidity and mortality. Nonetheless, nurses endure historical, societal, and professional barriers to be respected and independent. In the intensive care unit (ICU), critically ill, often unstable patients require nurses to respond quickly and adapt to each unique situation, which may mean migrating outside of formal rules, norms, and policies, or "rule-bending." However, as inherent subordinates of hospital administrators and physicians, rule-bending, no matter how well-intended, necessary, or benign, often cause nurses to function in a grey zone of vulnerability and risk. Aim: I sought to explore how ICU nurses conceive of personal and professional risk when exercising clinical autonomy at the bedside. Method: Using purposive and snowball sampling, I recruited a diverse sample of ICU nurses in Northern California. Subsequently, I interviewed 27 ICU nurses using a social constructivist grounded theory methodology over 7 months. Employing a constant comparison technique throughout iterative data collection and data analysis, I sought theoretical saturation and theory development. Findings: Nurses defined clinical autonomy as having a “presence” in decision making and feeling empowered to assert agency related to patients. Management support, trusting physician relationships based on established competence, experience, hospital type, shift, and gender impacted clinical autonomy. Many nurses exercised clinical autonomy freely, but when faced with challenges from physicians, resorted to strategies, such as "working the system" or playing “the doctor-nurse game” to achieve their goals. This may be viewed as transiently usurping power from established hierarchies to maintain a sense of control, self-esteem, and professionalism. Participants infrequently discussed risk, except related to fears of working outside their legal scope of practice. Few nurses discussed the risk related to physicians, such as disruptive behavior, and few acknowledged the risk of not acting autonomously. Although many nurses claimed they rarely violated formal rules, others acknowledged routine “rule-bending” that had become normalized as a means to provide what they deemed as the most appropriate care in an expedient manner. Nurses justified risk-taking by feeling comfortable and competent with their actions and being motivated as a patient advocate. Conclusion: Nurses conceived of risk in a wide range but focused instead of their abundant clinical autonomy and altruistic quality care they provided. Nurses managed risk by following rules when possible, avoiding physician conflict, and assuring manager and physician support if they bent the rules