Nurses have significant independent duties, in addition to just following orders

A September 2016 article in the Online Journal of Issues in Nursing discusses research into a new healthcare concept called medical error recovery.

The basic idea of medical error recovery stems from the fact that the significant attention over the past two decades on medical error prevention has yielded little results.

Medical error recovery shifts the focus from trying to prevent errors to having nurses trained to identify, interrupt, and correct medical errors before they threaten patient safety.

It is not surprising that the study found that more experienced, better trained nurses had a higher rate of medical error recovery, and that higher workloads decreased the rate.

Hospitals should encourage, promote, and train their nurses on how to intercept medical errors and make corrections before patients are harmed.

As a Houston, Texas medical malpractice attorney, I believe that medical error recovery is an encouraging and promising new development. For years, in reviewing medical records and prosecuting medical negligence lawsuits, I have been disturbed at the difference between the nursing care that the Texas Board of Nursing mandates, versus the care that is often actually provided in a typical hospital.

Nurses have significant independent obligations to patients

When followed, the Texas Board of Nursing rules and guidelines are powerful.

I used the words “when followed” deliberately.

In the course of filing medical negligence lawsuits on behalf of patients and their families, I get the opportunity to take the depositions of nurses frequently. Almost universally, these nurses have apparently been coached by hospital administrators and lawyers to testify that they have a minimal role in patient care. No reasonable patient would want one of these nurses taking care of them, based on their testimony of how little they believe they are required to do.

Principally, I have found that incompetent nurses believe that they are unable to do anything without permission or an order from a physician. This is simply absurd and not supported by the Texas Board of Nursing.

In reality, nurses are highly-trained and capable caregivers that can have a profound impact on patient safety.

The Texas Board of Nursing rules and regulations make it clear that all nurses, including licensed vocational nurses (LVNs) and registered nurses (RNs) owe independent duties to their patients. They cannot sit idly by, waiting for a physician to answer a page or call, while providing no appropriate nursing interventions. Rule 217.11 summarizes the standards for nursing practice, some of which I discuss below.

Knowing capabilities. When being assigned patient care, both LVNs and RNs are only supposed to accept assignments where they have adequate instruction, training, and supervision to provide a safe environment for patients. Nurses are responsible for obtaining any necessary instruction and supervision in order to implement nursing procedures and practices.

Six-step decision-making model. The high level of expected nursing thought processes is demonstrated by the Board’s recommendation that all nurses use a six-step decision-making model in making safe treatment decisions for patients.

The first step is whether the specific care provided is consistent with the Texas Nursing Practice Act, or the board rules and position statements. If so, then second, the nurse should consider where the activity is appropriately authorized by a physician order, if necessary, and if the care complies with policies and procedures.

The third step is to think about whether the proposed care is supported by research from nursing literature and national nursing organizations. This is a significant point, because the implication is that nurses are required to have independent study to keep up with current national nursing research.

The fourth step is to assess the nurses individual clinical competence to perform the task safely. The fifth step is whether the care at issue would be within the accepted standard of care for nurses. Again, this implies that nurses must be familiar with what reasonably prudent nurses would do under similar circumstances, which is what the standard of care is.

Finally, the sixth step is whether the nurse is prepared to accept the consequences of his or her actions. Nurses should always be willing to assume accountability for providing safe care.

Safe environment. Nurses are expected to implement measures to promote a safe environment for patients.

Don’t fly by the seat of their pants. Registered nurses are expected to use a systematic approach to provide individualized, goal-directed nursing care. This involves performing comprehensive nursing assessments, making nursing diagnoses that serve as the basis for the strategy of care, developing a plan of care, implementing nursing care, and evaluating the patient’s responses to nursing interventions.

Medications. Nurses are required to know the rationale for and the effects of medications and treatments and must correctly administer them. This means that a nurse cannot simply follow a doctor’s order, but must independently understand the reason that the medication is prescribed and what it should do.

I have handled numerous cases, as a medical malpractice attorney, where nurses mindlessly followed physician orders for powerful pain medications, despite the fact that the patients’ status had deteriorated and the medications were actually causing harm.

The Board rule on medications demonstrates that quality nursing care requires an actively-engaged nurse who is constantly assessing and reassessing patients, and making modifications to the care plan.

Interventions. Nurses must independently institute appropriate nursing interventions that may be required to stabilize a patient’s condition or prevent complications.

Questionable orders. Nurses must clarify any order or treatment that the nurse has reason to believe is an accurate or contraindicated, and, if necessary notify the ordering doctor when the nurse decides not to administer the medication or treatment.

What you can do

I recommend that patients and family members do everything possible and practical to have a good relationship with nursing staff. Both licensed vocational nurses and registered nurses are an important part of the patient care team. Their independent duty to advocate for patient needs can come in handy, particularly when a doctor is nowhere to be found and something is terribly wrong.

On the other hand, I have had a lot of cases where the nurses provided care that reflected very little thought. I have described them as acting on autopilot. If you or someone you care for has been seriously injured by substandard care like this, call Painter Law Firm, at 281-580-8800, for a free consultation of your potential case by an experienced medical malpractice attorney.


Robert Painter is an attorney at Painter Law Firm PLLC, in Houston, Texas, where he investigates and files medical malpractice and wrongful death lawsuits on behalf of patients and their families.

Robert Painter
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Robert Painter

Robert Painter is an award-winning medical malpractice attorney at Painter Law Firm Medical Malpractice Attorneys in Houston, Texas. He is a former hospital administrator who represents patients and family members in medical negligence and wrongful death lawsuits all over Texas. Contact him for a free consultation and strategy session by calling 281-580-8800 or emailing him right now.