Threads of Counsel

I. Letting Go of Autonomy

“Nursing is an autonomous profession.”
It’s a phrase offered as proof of progress. A signal that we are no longer seen as just helpers, assistants, or extensions of someone else’s expertise. That we belong at the table, that nurses have earned our place.

The pursuit of autonomy has been hard-won. It has been a response to real harm: to exclusion from decision-making, to subordination under physician authority, to the erasure of nursing knowledge. For many, autonomy has offered protection—a way to reclaim power, demand respect, and hold ground in systems.

But I’ve been wondering: What happens when the frame we fought so hard to enter was never meant to hold us?

What if autonomy—at least as it’s been defined and pursued in nursing—was never the destination, but a detour? What if, in seeking to be seen as autonomous, nurses have started to sever ourselves from the very thing that makes nursing most powerful: our ability to care, to relate, to build trust in places where trust has been broken? What do we lose when we tie our worth to autonomy?

To ask this isn’t to diminish the labor it took to get here.
This is not an argument against the nurses who have demanded more.
It’s not a dismissal of those who’ve pushed for policy change, expanded scope, or fought to practice without supervision. Those efforts matter. They’ve opened doors. They’ve made space.

But we also have to name what autonomy has come to mean. Even when softened by ethics or framed as collaborative, it still centers independence. It still imagines the nurse as a siloed actor. And it still frames legitimacy in terms drawn from medicine, STEM, and systems that prize authority over relationship.

This essay is not a call to return to obedience. It’s a call to rethink what nursing is building—and why.
To question whether autonomy is actually the measure we want.
To consider that maybe, the heart of nursing has never been about standing apart—but about showing up with.

What follows is both critique and offering: a recognition of how we got here, and a proposal for where we might go next. A vision of nursing that draws power not from separation or status, but from interdependence, accountability, and care as practice.

II. The Making of a Metric: Autonomy, Legibility, and What Got Lost Along the Way

For more than a century, nursing has sought to be seen. Not just by patients, but by institutions—by regulators, insurers, policymakers, and other professions whose frameworks determine what counts as legitimate labor. To meet those expectations, nursing has often had to translate its value into terms those systems understand: what can be charted, billed, measured, or standardized.

This pursuit of legibility was not a mistake—but it came at a cost. In elevating biomedical expertise and procedural efficiency, systems often failed to account for the forms of nursing knowledge that resist quantification: relational insight, cultural navigation, and intuitive care. Autonomy emerged as a symbol of legitimacy—a way to signal professional standing in environments that devalue presence and interdependence.

But the elevation of autonomy was not inevitable. It was shaped by history, policy, and power. And in following that path, nursing may have been pulled away from some of its deepest roots.

A. Subordinate by Design: Gendered and Racialized Origins of Nursing
Modern nursing took shape in the 19th century within a structure of obedience, not independence. While Florence Nightingale is often credited with professionalizing the field, her model reinforced Victorian ideals of purity, deference, and whiteness. It created a path into public life for middle- and upper-class white women—while simultaneously excluding Black, Indigenous, and working-class women from early training programs.

Nursing schools formalized this dynamic. Students lived under strict discipline and were evaluated not on clinical reasoning but on obedience and cleanliness. Their value was defined by how well they supported—not challenged—the physician’s plan.

Yet beneath that structure lived a different kind of expertise: careful observation, embodied advocacy, and relational presence. These practices were rarely named as skills, but they formed the foundation of the work—and they still do.

As nursing sought greater professional recognition, systems demanded evidence of competence in quantifiable terms. Technical knowledge was elevated. Managerial fluency became prized. And in that context, autonomy began to emerge as a proxy for power: if nurses could make independent decisions, perhaps they would finally be recognized as equals.

B. Science, Scope, and the Expansion of Roles
By the mid-20th century, healthcare systems were rapidly expanding—and with them, so were nursing roles. Public health nurses, psychiatric nurses, and nurse practitioners entered the scene with broader responsibilities, more advanced education, and deeper involvement in patient care. Autonomy became part of this evolution—not just in tasks performed, but in the language used to describe what made a nurse “advanced” or “professional.”

Theorists like Virginia Henderson, Dorothea Orem, and Hildegard Peplau developed models that redefined nursing as distinct from medicine. Henderson emphasized patient independence as a goal of care. Orem outlined a self-care framework that underscored the nurse’s role in supporting autonomy. Peplau introduced the theory of interpersonal relations, positioning the nurse-patient relationship as central to healing. These frameworks were revolutionary—but to gain traction, they had to speak the language of science, system logic, and professional differentiation.

As nursing adopted these models and embraced advanced practice, professional legitimacy became increasingly tied to clinical complexity and institutional alignment. Nurses working in intensive care, academic settings, or specialized units were seen as operating at “the top of their license.” Meanwhile, community health nurses, rural practitioners, and bedside caregivers—often doing the most relational work—were rendered less visible in the profession’s public image.

Autonomy, in this context, became a sorting mechanism. It marked who counted as a “real” nurse—not just in public perception, but within the profession itself.

C. Autonomy as Ethical Imperative
In the 1970s, as civil rights and patient advocacy movements gained ground, the nursing profession began to frame autonomy not just as a functional goal but as an ethical one. The American Nurses Association’s Code of Ethics emphasized the nurse’s role in protecting patient dignity, advocating for those in harm’s way, and upholding moral agency—even in opposition to institutional norms.

This shift was deeply significant. It enabled nurses to resist paternalism, speak out against injustice, and assert authority in care planning. But it also reframed what professional excellence looked like. The “good” nurse was increasingly the one who acted independently—who could advocate alone, intervene alone, and think alone within a set of institutional rules.

Autonomy became a stand-in for integrity. And over time, relationality—though ever present in practice—was framed as secondary. Not absent, but overshadowed.

D. The Credentialing Era: Autonomy in the Age of Metrics
In recent decades, nursing’s pursuit of autonomy has increasingly intertwined with credentialing systems, degree inflation, and the metrics of neoliberal professionalism. Movements like BSN-in-10, the expansion of Doctor of Nursing Practice (DNP) programs, and efforts to classify nursing as a STEM field all reflect this trend. They position nursing as a scientifically rigorous, economically productive discipline—worthy of funding, policy inclusion, and billing authority.

But these reforms have also stratified the field. Nurses in urban hospitals, academic centers, or tech-adjacent specialties are often elevated as exemplars of the profession. Meanwhile, Licensed Practical Nurses (LPNs), Certified Nursing Assistants (CNAs), internationally educated nurses (IENs), and community-based caregivers remain peripheral in autonomy discourses—despite their frontline expertise.

Professional power increasingly depends on credentials, not just experience. Magnet status, for instance, privileges institutions that meet certain academic and professional development benchmarks. Some states require master’s or doctoral preparation for independent practice. And reimbursement policies reward nurses who can bill directly—further linking legitimacy to proximity with systems of measurement and control.

The result is a professional hierarchy that mirrors broader healthcare inequities. Efficiency is rewarded over presence. Knowledge is counted when it is credentialed. And care—especially relational care—risks being devalued if it cannot be translated into a billing code.

II.a. Returning to the Root: What Are We Nurturing?

The word nurse comes from the Latin nutrire: to nourish, to nurture, to sustain. Its origins weren’t clinical. They were relational. Embodied. Intimate.

Nursing began in proximity—to blood, to breath, to grief. It meant being close enough to feed, hold, clean, witness. It meant tending to what couldn’t be rushed, standardized, or outsourced.

But somewhere along the way, we began measuring something else.

So I keep asking: What are we nurturing now?
Are we growing our capacity to connect? To stay present in the mess and slowness of healing? Or are we nurturing frameworks that prioritize documentation, delegation, and distance?

This isn’t a rejection of skill, science, or structure. It’s a call to remember the soil we grow from. Because if nursing is rooted in nurture, then our legitimacy must come from relationship—not just regulation.

And so this question lingers, quiet but persistent:
Are we still tending to people? Or are we now mostly tending to the idea of ourselves as professionals?

III. The Refusal to Be Redefined: What the Doula Movement Offers Nursing

While nursing has spent generations shaping itself to meet institutional demands—through licensure, reimbursement, and respectability—many doulas have chosen a different path. One grounded not in assimilation, but in community. Their refusal isn’t about rejecting standards of care. It’s about refusing to be remade by systems that have never recognized the wisdom of relational labor, ancestral practice, or embodied presence.

As Medicaid reimbursement expands for doula services, many Black, Indigenous, and community-based doulas are speaking out. They aren’t demanding recognition—they already have it. They are trusted in their communities, situated in movements for reproductive justice, and guided by long-standing traditions of care. What they reject is the idea that legitimacy must be filtered through certification, codified training, or billing structures designed by people who have never stood beside a birthing person unless they were being paid to manage the outcome.

A. Reclaiming Expertise Without Translation
For Black and Indigenous doulas in particular, this is not a philosophical disagreement—it is survival.

Organizations like Ancient Song Doula Services, the Black Mamas Matter Alliance, and Sista Midwife Productions are building ecosystems of care, advocacy, and education that center community needs over institutional comfort. Rooted in the reproductive justice framework created by Black women organizers in the 1990s, their work affirms the right to have children, not have children, and raise families in safe, supported environments.

This is expertise. But when Medicaid programs offer reimbursement only to doulas trained by state-approved certifying bodies—most often DONA International—they deny that truth. DONA has long prioritized white, apolitical, hospital-aligned models of care. Its training frameworks discourage advocacy, encourage deference, and pressure doulas to prioritize medical “collaboration” over client protection. This is not about training quality. It’s about gatekeeping that silences the political roots of care.

B. Community Accountability as a Governance Model
In place of state oversight or licensure, many doula networks have developed community-based models of accountability. These are not vague or unstructured. They are rooted in relationship, in reciprocity, and in shared responsibility to those they serve.

When states say: you can’t bill unless you train under someone we approve, many doulas say: then we won’t bill. But we will still be here.

This is not a rejection of compensation. It is a rejection of capture. A refusal to let Medicaid reimbursement become the wedge by which care is made sterile, standardized, and extractive.

C. What They Are Building
This is not just a doula story. It is a story about what happens when people who have always cared are told their care must now be made “professional.” It is a warning—and a blueprint.

Doulas working from the margins—especially in Black, Indigenous, queer, rural, and disabled communities—are modeling something else entirely: a vision of care that is accountable to the people it serves, not the systems that exploit them.

They are not less skilled. They are skilled differently.
They are not untrained. They are trained outside.
They are not resisting professionalism. They are redefining what care makes possible—without abandoning the communities they come from.

D. Implications for Nursing
Nurses should be paying attention.
Doulas are not behind us on the professionalization timeline—they are ahead of us on a different road. They are reminding us that care does not need to be certified to be sacred. That legitimacy does not come from alignment with institutions, but from relationship, trust, and political clarity.

They are showing us what it means to build a profession around presence, not permission.

IV. The STEM Rebrand and the Problem of Proving Our Worth

In recent years, a growing movement has sought to classify nursing as a STEM discipline—Science, Technology, Engineering, and Mathematics. Proponents argue that this shift will bring federal funding, educational inclusion, and greater policy clout. It’s a rebrand designed to translate nursing into the language of systems that reward technological advancement and quantifiable outcomes.

But what are we giving up to be understood this way?

A. STEM as a Funding Strategy
The appeal of STEM is pragmatic. STEM disciplines receive disproportionate federal investment through NIH grants, education pipelines, and research infrastructure. Programs labeled STEM are prioritized in policy, scholarship allocation, and institutional strategy. By aligning with STEM, nursing opens doors to these resources—especially at a time when clinical innovation is often equated with data fluency and technological competency.

But access often comes with assimilation. When legitimacy is tied to STEM, nursing may be pressured to showcase its value in terms defined by those systems: output, automation, evidence-based protocols, and documentation metrics. What can’t be measured is often what gets cut.

B. The Risk of Reframing the Discipline
Framing nursing as a STEM field may elevate the profession’s public image—but it risks narrowing its internal identity. If our curricula, research agendas, and hiring priorities begin to follow STEM’s technocratic logic, we may lose the parts of nursing that resist that framing: intuition, cultural attunement, grief work, presence.

Nurses who build trust across difference, who sense when something’s off without a diagnostic code, who hold space for patients when medicine can’t offer a cure—those forms of expertise are not anti-science. But they are often undervalued in systems that only reward what can be abstracted and counted.

C. What Nursing Reveals That STEM Erases
The question isn’t just whether nursing can be STEM. It’s whether STEM can hold what nursing knows.

Nursing makes visible the unmeasurable: the long pause at the bedside, the weight of a held hand, the wisdom shared in break rooms and shift reports, the meaning found in silence, laughter, and the smell of a wound before it changes color. These are not soft extras. They are clinical knowledge—relational, embodied, hard-won.

And they are in danger of being erased.

D. The Work Ahead
This is not a rejection of science. It’s a rejection of a narrow vision of science—one that privileges efficiency over empathy, speed over depth, metrics over meaning.

If we reshape ourselves to win access to systems that only recognize part of what we do, we may gain funding but lose our foundation.

Nursing does not need to become more like STEM to matter. It needs to be funded, valued, and protected as it is—in its full, relational, and rigorously human form.

V. Automation and the Erosion of Relational Practice

The integration of artificial intelligence into healthcare is accelerating. Algorithms now determine patient risk scores. Charting bots summarize assessments. Predictive models recommend interventions. These technologies are designed to maximize efficiency, reduce variation, and drive productivity—the core imperatives of a healthcare system increasingly shaped by capitalist and technocratic logics.

For nurses, this raises a central tension: if our professional legitimacy has been defined by clinical tasks that machines can now perform—what remains distinct about what we do?

A. Machines Reflect the Priorities of Power
AI is often described as neutral, but it is anything but. It reflects the values of the systems that design and deploy it. In healthcare, that means privileging speed, scale, and data capture. Machine learning models don’t evolve in a vacuum—they’re trained on what institutions already track: billing codes, risk scores, throughput metrics.

As a result, AI replicates and reinforces a narrow conception of care: one optimized for extractive systems, not human flourishing. It doesn’t just take on clinical tasks. It reorganizes the definition of care itself—stripping it down to what can be encoded, tracked, and monetized.

And because those are the forms of labor that institutions reward, they’re increasingly what nursing is expected to emulate.

B. What Machines Can’t Do—And What We Must Defend
Artificial intelligence can process information, but it cannot interpret context. It can identify risk, but it cannot understand meaning. It cannot detect silence as a form of resistance. It cannot sense fear beneath compliance. It cannot navigate the nuances of a patient’s cultural identity, respond to trauma in real time, or choose to pause rather than push.

Nursing, at its best, is not simply responsive—it is attuned. It is situated in community, shaped by memory, and practiced in relationship. It includes cultural translation, emotional scaffolding, anticipatory grief work, and education grounded in both science and justice.

This is not “extra” labor. This is nursing. And it does not appear in data sets—not because it lacks value, but because the system has never known how to measure it.

If nursing does not name and defend this work as clinical, it will continue to be marginalized—and eventually erased.

C. Care as the Center, Not the Residue
If care is treated as what remains after the “real” thinking has been automated, we have misunderstood the future we’re walking toward. Care is not what’s left. It is what must lead.

AI has the potential to reduce burden—but only if we use the space it creates to deepen our presence, not retreat from it. If we are clear about what we are protecting, AI could support the restoration of nursing’s fullest scope: relational, political, embodied, and wise.

But if we continue to chase legitimacy by mimicking the priorities of machines, we will design a profession that no longer needs us.

If care is the most irreplaceable part of what we do, it must be the most defended.

VI. Reframing Legitimacy: What Fakher’s Vision Reveals

In early 2025, nurse leader Ali Fakher argued that nursing must be recognized as a “knowledge-driven discipline” to gain systemic power. His proposed path includes independent practice authority, direct reimbursement, and a decisive move away from nursing’s identity as a “caring profession.” The message is: if nursing wants influence, it must align itself with the language of systems—scope, science, billing, and data.

The appeal of this argument is obvious. Nursing has long been marginalized, dismissed as subordinate or sentimental. Fakher’s reframing offers a powerful counter-narrative: nurses are not assistants, but thinkers. Not soft, but strategic.

A. Care Has Always Been Knowledge
The problem isn’t that nursing has been too rooted in care. The problem is that care has been treated as less legitimate—dismissed by systems that value what is quantifiable over what is relational, measurable over embodied.

But care is clinical judgment expressed through relationship. It’s knowing when to wait, how to listen, who to call, and what not to ask yet. It’s culturally responsive education, trauma-informed assessment, and intuition backed by years of pattern recognition. It is knowledge—but knowledge that refuses to flatten people into symptoms or procedures.

If we abandon care to be seen as smart, we’ve already conceded the most radical parts of our practice.

B. The Discipline We Already Are
We don’t need to rebrand care as knowledge. It always has been. The work now is to make visible what systems have failed to measure. To elevate the forms of expertise that live in bodies, in stories, in relationships—and to resist the pressure to collapse that complexity into codes and credentials.

Nursing is already a knowledge-driven discipline. But it is one that understands knowledge as something lived, shared, and held in community—not just published, billed, or abstracted.

VII. What Happens to the Patient?

In all the discourse around nursing autonomy, STEM designation, credentialism, and systemic legitimacy, one figure remains curiously underexamined: the patient—not as a diagnosis, a compliance target, or a satisfaction score, but as a person shaped by history, culture, and power.

That absence isn’t incidental. It reveals a shift in what we center. And if nursing continues to prioritize authority over relationship, institutional visibility over cultural humility, the patient will remain peripheral to our professional identity—even in a field that claims to be “patient-centered.”

A. Patient-Centeredness, Misunderstood
Contemporary models of patient-centered care often collapse into performance. They become scripts for engagement, checkboxes in the chart, gestures rehearsed for reimbursement. But nursing theorists like Mary Koithan and Madeleine Leininger have long argued that true patient-centeredness is not a tactic—it’s an epistemology. One that requires relational knowing, cultural attunement, and an ethical discomfort with standardization.

As Leininger wrote, “Care is the essence of nursing and the dominant, distinctive, and unifying feature.” In her model of transcultural nursing, care cannot be detached from the patient’s cultural context. It’s not enough to inform patients—we must learn to listen across difference, especially when that difference unsettles our assumptions.

In this framing, patient-centeredness becomes more than a method. It becomes a moral and cultural obligation.

B. Cultural Safety and System Awareness
Models such as Campinha-Bacote’s Process of Cultural Competence, Papadopoulos’ framework for transcultural health, and Lisa Bourque Bearskin’s Indigenous lens on cultural safety push this even further. They position care within histories of oppression and ask nurses to build not just cultural knowledge, but structural fluency—the ability to recognize how policy, poverty, racism, housing, incarceration, and colonialism shape what happens in the clinical encounter.

Bearskin reminds us that cultural safety demands a reckoning with power. It means understanding when “autonomy” is used to disguise coercion, or when “compliance” is weaponized against marginalized patients. These frameworks clarify: there is no such thing as neutral care. You cannot be patient-centered without being system-aware.

C. Relational Practice as Political Praxis
Relational care is not soft. It is not subordinate. And it is not an alternative to clinical skill—it is one of nursing’s most critical forms of expertise.

It’s how we know when a patient is off before the labs say so. It’s how we decide which sibling to call, what language to slow down in, and which questions not to ask—yet. It’s how we recognize violence wrapped in protocol and know when to make space instead of moving forward.

Nurses like Peplau and Watson framed relational practice as central to healing. But it’s also central to safety—especially for those whose bodies, histories, and communities are too often misread or erased. Relational care is how we protect patients in systems that have not always been built for them.

D. Don’t Center Nursing and Lose the Patient
When professional discourse becomes consumed with autonomy, legitimacy, and recognition, it risks turning inward. Patients become supporting characters. Communities become data sets. Doulas, CNAs, IENs, and uncredentialed care workers are treated as peripheral—despite often holding the deepest relationships with patients.

Leading with care doesn’t mean rejecting professional growth. It means ensuring that growth remains accountable to the people we serve.

Because the question isn’t just whether nursing deserves more recognition.
It’s whether the people we care for will still be recognized in the future nursing is building.

Conclusion: We Know What We’re Doing

Nursing is not adrift. It is strategic, grounded, and relational—despite systems that try to flatten it, silence it, or reshape it in someone else’s image.

We are not waiting to become legitimate. Not through billing codes. Not through STEM validation. Not through proximity to medical power.
We are already here.

The question is not whether nursing can rise to meet the future. The question is whether we’ll do it by reproducing the very structures that devalue care—or by building something else entirely, rooted in what nurses have always known:
That presence is power.
That care is a form of knowledge.
That relationship—not control—is what saves lives.

Autonomy is not inherently liberatory. It is not neutral. It carries a history, a politics, and a default shape that too often mirrors the systems we claim we want to transform.

If we center care—relational, political, embodied, and wise—nursing doesn’t need to chase legitimacy. We remember that we already have it.