I. Letting Go of Autonomy
“Nursing is an autonomous profession.”
The phrase gets offered as proof of progress, evidence that we are no longer seen as helpers or assistants or extensions of someone else’s expertise. We belong at the table. We earned the seat.
The pursuit of autonomy has been hard-won, and it answered real harm: exclusion from decision-making, subordination to physician authority, the erasure of nursing knowledge. Autonomy has offered protection, a way to reclaim power, demand respect, and hold ground.
But I keep wondering what happens when the frame we fought so hard to enter was never built to hold us.
What if autonomy, at least as nursing has defined and pursued it, was a detour rather than a destination? What if the effort to be seen as autonomous has started to sever us from the thing that makes nursing most powerful, our capacity to care, to relate, to build trust where trust has been broken? What do we lose when we tie our worth to autonomy?
Asking this does not diminish the labor it took to get here. I am not arguing against the nurses who demanded more, or against anyone who pushed for policy change, expanded scope, or the right to practice without supervision. Those efforts opened doors. They made space.
Still, we have to name what autonomy has come to mean. Even when it is softened by ethics or dressed up as collaborative, it centers independence. It imagines the nurse as a siloed actor. It measures legitimacy against medicine, STEM, and other systems that prize authority over relationship.
This essay is not a call to return to obedience. It asks what nursing is building and why, whether autonomy is the measure we actually want, and whether the heart of this work has ever been about standing apart rather than showing up with.
What follows is a critique and an offering: how we got here, and where we might go next. Nursing draws its power from interdependence, accountability, and care as practice, not from separation or status.
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 only by patients, but by institutions: regulators, insurers, policymakers, and the other professions whose frameworks decide what counts as legitimate labor. Meeting those expectations meant translating nursing’s value into terms those systems already understood, which is to say whatever could be charted, billed, measured, or standardized.
Legibility was not a mistake, but it cost us something. Systems that elevate biomedical expertise and procedural efficiency have no good way to account for relational insight, cultural navigation, or judgment that arrives before the data does. Autonomy emerged as the available symbol of legitimacy, a way to signal professional standing in environments that discount presence and interdependence.
That elevation was not inevitable. History, policy, and money shaped it. Following that path pulled nursing 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 inside a structure built for obedience. Florence Nightingale is usually credited with professionalizing the field, but her model reinforced Victorian ideals of purity, deference, and whiteness. It opened a path into public life for middle- and upper-class white women while excluding Black, Indigenous, and working-class women from early training programs.
Nursing schools formalized the arrangement. Students lived under strict discipline and were evaluated on obedience and cleanliness rather than clinical reasoning. Their value lay in how well they supported the physician’s plan.
Underneath that structure lived another kind of expertise: careful observation, embodied advocacy, relational presence. These were rarely named as skills. They were the foundation of the work, and they still are.
When nursing pressed for recognition, the systems it approached wanted competence demonstrated in quantifiable terms. Technical knowledge rose. Managerial fluency became an asset. Autonomy started to function as a proxy for power, on the theory that nurses who could make independent decisions might finally be treated as equals.
B. Science, Scope, and the Expansion of Roles
By the mid-20th century, healthcare systems were expanding fast, and nursing roles expanded with them. Public health nurses, psychiatric nurses, and nurse practitioners took on broader responsibilities, more advanced education, and deeper involvement in patient care. Autonomy became part of that evolution, showing up in the tasks nurses performed and in the language used to describe what made a nurse “advanced” or “professional.”
Virginia Henderson, Dorothea Orem, and Hildegard Peplau developed models that defined nursing as distinct from medicine. Henderson made patient independence a goal of care. Orem built a self-care framework that put the nurse in the role of supporting autonomy. Peplau’s theory of interpersonal relations placed the nurse-patient relationship at the center of healing. These frameworks were revolutionary, and to get traction they had to speak in the register of science, system logic, and professional differentiation.
As advanced practice grew, legitimacy attached itself to clinical complexity and institutional alignment. Nurses in intensive care, academic centers, and specialized units were described as working at “the top of their license.” Community health nurses, rural practitioners, and bedside caregivers, who often do the most relational work, faded from the profession’s public image.
Autonomy became a sorting mechanism. It marked who counted as a real nurse, in public perception and inside the profession itself.
C. Autonomy as Ethical Imperative
In the 1970s, as civil rights and patient advocacy movements gained ground, nursing began framing autonomy as an ethical commitment rather than a functional goal. The American Nurses Association’s Code of Ethics emphasized protecting patient dignity, advocating for people in harm’s way, and maintaining moral agency even against institutional norms.
That shift mattered. It gave nurses grounds to resist paternalism, speak against injustice, and claim authority in care planning. It also reshaped what excellence looked like. The good nurse became the one who acted independently, who could advocate alone, intervene alone, and reason alone inside a set of institutional rules.
Autonomy started standing in for integrity. Relationality stayed present in the actual work and slipped into the background of how the profession described itself.
D. The Credentialing Era: Autonomy in the Age of Metrics
In recent decades, autonomy has tangled with credentialing systems, degree inflation, and the metrics of neoliberal professionalism. BSN-in-10, the growth of Doctor of Nursing Practice programs, and the campaign to classify nursing as a STEM field all point the same direction. They present nursing as scientifically rigorous and economically productive, and therefore worth funding, policy inclusion, and billing authority.
These reforms also stratified the field. Nurses in urban hospitals, academic centers, and tech-adjacent specialties get held up as exemplars of the profession. Licensed Practical Nurses, Certified Nursing Assistants, internationally educated nurses, and community-based caregivers stay peripheral to autonomy discourse despite their frontline expertise.
Professional power now depends on credentials more than on experience. Magnet status rewards institutions that hit particular academic and professional development benchmarks. Some states require master’s or doctoral preparation for independent practice. Reimbursement policy favors nurses who can bill directly, tying legitimacy to proximity to systems of measurement and control.
The resulting hierarchy mirrors the inequities of the wider healthcare system. Efficiency outranks presence. Knowledge counts once it is credentialed. Relational care risks being treated as worthless because no one has written a billing code for it.
II.a. Returning to the Root: What Are We Nurturing?
The word nurse comes from the Latin nutrire: to nourish, to nurture, to sustain. The origins were not 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 could not be rushed or standardized or outsourced.
Somewhere along the way we began measuring something else.
So I keep asking what we are 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 reward documentation, delegation, and distance?
None of this rejects skill or science or structure. It asks us to remember the soil we grow from. If nursing is rooted in nurture, our legitimacy has to come from relationship and not only from regulation.
The question sits there quietly. Are we still tending to people, or mostly tending to the idea of ourselves as professionals?
III. The Refusal to Be Redefined: What the Doula Movement Offers Nursing
While nursing spent generations reshaping itself to meet institutional demands through licensure, reimbursement, and respectability, many doulas took a different path, one grounded in community rather than assimilation. Their refusal is not about lowering standards of care. It is about declining to be remade by systems that have never recognized relational labor, ancestral practice, or embodied presence as forms of knowledge.
As Medicaid reimbursement expands for doula services, Black, Indigenous, and community-based doulas are speaking up. They are not asking to be recognized. They already are, by the people they serve, inside movements for reproductive justice, and through long traditions of care. What they reject is the premise that legitimacy has to pass through certification, codified training, and billing structures written by people who have never stood beside a birthing person except to manage an outcome.
A. Reclaiming Expertise Without Translation
For Black and Indigenous doulas, this is a matter of survival rather than philosophy.
Ancient Song Doula Services, the Black Mamas Matter Alliance, and Sista Midwife Productions are building ecosystems of care, advocacy, and education that answer to community need instead of institutional comfort. Their work grows out of the reproductive justice framework Black women organizers built in the 1990s, which affirms the right to have children, the right not to, and the right to raise families in safe and supported conditions.
That is expertise. When Medicaid programs reimburse only doulas trained by state-approved certifying bodies, they deny it. Where states route approval through legacy organizations like DONA International, the effect is to privilege a white, apolitical, hospital-aligned model of doula work, one that treats advocacy as a boundary violation and pushes doulas toward collaboration with clinicians over protection of the client. Nothing about that arrangement improves the quality of training. It sets a gate, and what gets gated out is the political history of the work.
B. Community Accountability as a Governance Model
In place of state oversight and licensure, many doula networks have built accountability inside relationship: reciprocity, shared obligation, answering directly to the people they serve. These structures are not loose or improvised. They are simply not administered by an agency.
When a state says you cannot bill unless you train under someone we approve, plenty of doulas answer that they will not bill and will still be here.
Refusing capture is not the same as refusing compensation. The concern is that reimbursement becomes the wedge that makes care sterile, standardized, and extractive.
C. What They Are Building
This is a story about what happens when people who have always done the caring are told their care must now be made professional. It works as a warning and as a blueprint.
Doulas in Black, Indigenous, queer, rural, and disabled communities are modeling care accountable to the people it serves rather than to the systems that profit from them. They are trained outside the approved pathways, skilled in ways those pathways do not test, and clear-eyed about what recognition would cost them.
D. Implications for Nursing
Nurses should be paying attention. Doulas are not behind us on a professionalization timeline. They are further along a different road, and they are demonstrating that care does not have to be certified to be trusted, and that legitimacy can come from relationship and political clarity instead of institutional alignment.
They are building a profession around presence rather than permission.
IV. The STEM Rebrand and the Problem of Proving Our Worth
A growing movement wants nursing classified as a STEM discipline. Proponents argue the change would bring federal funding, educational inclusion, and policy clout. It is a rebrand designed to translate nursing into the language of systems that reward technological advancement and quantifiable outcomes.
The question is what we give up to be understood that way.
A. STEM as a Funding Strategy
The appeal is practical. STEM disciplines pull disproportionate federal investment through NIH grants, education pipelines, and research infrastructure. The STEM label shapes policy priority, scholarship allocation, and institutional strategy. Aligning with it opens those doors at a moment when clinical innovation is routinely equated with data fluency and technological competency.
Access tends to come with assimilation. Tie legitimacy to STEM and nursing will be pressured to demonstrate value on STEM’s terms: output, automation, evidence-based protocols, documentation metrics. Whatever cannot be measured is what gets cut.
B. The Risk of Reframing the Discipline
Framing nursing as STEM may lift the profession’s public image while narrowing its internal identity. If curricula, research agendas, and hiring priorities follow technocratic logic, we lose the parts of the work that resist it: intuition, cultural attunement, grief work, presence.
Nurses who build trust across difference, who notice something is wrong before there is a code for it, who stay with patients when medicine has nothing curative left, are not practicing outside of science. Their expertise goes undervalued because the systems doing the valuing only reward what abstracts and counts cleanly.
C. What Nursing Reveals That STEM Erases
The real question is whether STEM can hold what nursing knows.
Nursing makes the unmeasurable visible: the long pause at the bedside, the weight of a held hand, what gets passed along in break rooms and shift reports, the meaning in silence and laughter, the smell of a wound before it changes color. This is clinical knowledge, relational and embodied and hard-won, and it is in danger of being erased.
D. The Work Ahead
Science is not the problem. The problem is a narrow version of it, one that privileges efficiency over empathy and metrics over meaning.
If we reshape ourselves to gain access to systems that recognize only part of what we do, we may win funding and lose the foundation. Nursing does not need to become more like STEM to matter. It needs to be funded, valued, and protected in its full relational form.
V. Automation and the Erosion of Relational Practice
The integration of artificial intelligence into healthcare is accelerating. Algorithms generate patient risk scores. Charting bots summarize assessments. Predictive models recommend interventions. These tools are built to maximize efficiency, reduce variation, and raise productivity, which are the governing imperatives of a healthcare system shaped by capital.
For nurses that raises a hard question. If our professional legitimacy rests on clinical tasks a machine can now perform, what remains distinct about what we do?
A. Machines Reflect the Priorities of Power
AI gets described as neutral and it is nothing of the kind. It carries the values of whoever designs and deploys it. In healthcare that means speed, scale, and data capture. Machine learning models train on what institutions already track: billing codes, risk scores, throughput metrics.
So AI reproduces a narrow conception of care, optimized for extractive systems rather than for people getting better. It takes on clinical tasks and reorganizes the definition of care around what can be encoded and monetized. Those are also the forms of labor institutions reward, and increasingly what nursing is expected to imitate.
B. What Machines Cannot Do, and What We Have to Defend
Artificial intelligence processes information without interpreting context. It flags risk without understanding meaning. It cannot read silence as resistance or fear underneath compliance, cannot navigate the specifics of a patient’s cultural identity, cannot respond to trauma as it surfaces, cannot decide to pause instead of push.
Good nursing is attuned. It is situated in community, shaped by memory, practiced in relationship. It includes cultural translation, emotional scaffolding, anticipatory grief work, and teaching grounded in science and in justice.
This is nursing, not extra labor layered on top of it. It does not appear in the datasets because the system never learned how to measure it. If we do not name and defend this work as clinical, it stays marginal and eventually disappears.
C. Care as the Center, Not the Residue
If care is what remains after the real thinking has been automated, we have misread the future we are walking into. Care has to lead.
AI could reduce burden. Whether it does depends on whether we use the space it opens to deepen presence or to retreat from it. Used with clarity about what we are protecting, it could help restore nursing’s fullest scope: relational, political, embodied. Used to chase legitimacy by mimicking the priorities of machines, it builds a profession that no longer needs us.
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 in order to hold systemic power. His proposed path includes independent practice authority, direct reimbursement, and a deliberate move away from nursing’s identity as a caring profession. The message is that influence requires speaking the language of scope, science, billing, and data.
The appeal is obvious. Nursing has been dismissed as subordinate and sentimental for a long time, and Fakher’s reframing answers that dismissal directly. Nurses are thinkers. Nurses are strategic.
A. Care Has Always Been Knowledge
The problem was never that nursing was too rooted in care. It was that care got treated as the less legitimate thing by systems that value the quantifiable over the relational and the measurable over the embodied.
Care is clinical judgment expressed through relationship. It is knowing when to wait, how to listen, who to call, and what not to ask yet. It is culturally responsive teaching, trauma-informed assessment, pattern recognition built over years. It is knowledge that refuses to flatten a person into symptoms and procedures.
Abandoning care in order to be taken seriously concedes the most radical part of the practice.
B. The Discipline We Already Are
Care does not need to be rebranded as knowledge. It has always been knowledge. The work is to make visible what these systems failed to measure, to elevate expertise that lives in bodies and stories and relationships, and to resist collapsing that complexity into codes and credentials.
Nursing is already a knowledge-driven discipline. It just understands knowledge as something lived, shared, and held in common rather than published, billed, and abstracted.
VII. What Happens to the Patient?
In all the discourse about nursing autonomy, STEM designation, credentialism, and systemic legitimacy, one figure goes strangely underexamined: the patient, not as a diagnosis or a compliance target or a satisfaction score, but as a person shaped by history, culture, and power.
The absence tells us something about what we have centered. If nursing keeps prioritizing authority over relationship and institutional visibility over cultural humility, the patient stays peripheral to our professional identity even in a field that calls itself patient-centered.
A. Patient-Centeredness, Misunderstood
Contemporary patient-centered care models often collapse into performance: scripts for engagement, checkboxes in the chart, gestures rehearsed for reimbursement. Nursing theorists including Mary Koithan and Madeleine Leininger argued that real patient-centeredness is an epistemology rather than a tactic, one that requires relational knowing, cultural attunement, and an ethical discomfort with standardization.
Leininger described care as the essence of nursing, its dominant and unifying feature. In her model of transcultural nursing, care cannot be detached from the patient’s cultural context. Informing patients is not enough. We have to listen across difference, especially when the difference unsettles our assumptions. Patient-centeredness in that framing becomes a moral and cultural obligation rather than a method.
B. Cultural Safety and System Awareness
Campinha-Bacote’s Process of Cultural Competence, Papadopoulos’ framework for transcultural health, and Lisa Bourque Bearskin’s Indigenous lens on cultural safety push further. They situate care inside histories of oppression and ask nurses for structural fluency alongside cultural knowledge, meaning the ability to see how policy, poverty, racism, housing, incarceration, and colonialism shape what happens in a clinical encounter.
Bearskin’s account of cultural safety demands a reckoning with power. It means recognizing when autonomy is used to disguise coercion, and when compliance is weaponized against marginalized patients. There is no neutral care. You cannot be patient-centered without being system-aware.
C. Relational Practice as Political Praxis
Relational care is one of nursing’s most demanding forms of expertise. It is how we know a patient is off before the labs say so. It is how we decide which sibling to call, what language to slow down in, which question to hold for later. It is how we recognize violence wrapped in protocol and make space instead of moving forward.
Peplau and Watson framed relational practice as central to healing. It is also central to safety, particularly for patients whose bodies and histories and communities get misread or erased. Relational care is how we protect people inside systems that were not built for them.
D. Don’t Center Nursing and Lose the Patient
When professional discourse fixates on autonomy and recognition, it turns inward. Patients become supporting characters. Communities become data sets. Doulas, CNAs, internationally educated nurses, and uncredentialed care workers get treated as peripheral even though they often hold the closest relationships with patients.
Leading with care does not mean refusing professional growth. It means keeping growth accountable to the people we serve. Recognition for nursing is one question. Whether the people we care for will still be recognizable in the profession we are building is a different one, and it is the one that keeps me up.
Conclusion: We Know What We’re Doing
Nursing is not adrift. The work is strategic, grounded, and relational, despite systems that keep trying to flatten it, silence it, or reshape it in someone else’s image.
We are not waiting on billing codes or STEM validation or proximity to medical power in order to become legitimate. We are already here.
The question is how we meet what is coming. We can reproduce the structures that devalue care, or we can build something else out of what nurses have known all along, that presence is a form of power and that relationship, not control, is what keeps people alive.
Autonomy is not inherently liberatory and it is not neutral. It carries a history, a politics, and a default shape that too often mirrors the systems we say we want to transform.
If we lead with care, nursing does not have to chase legitimacy. We already have it.
Threads of Counsel 