Nurse mangers, charge nurses, and team leaders are responsible for promoting safe and effective patient care while maintaining the highest clinical standards in that setting. Not only must the team leader be an expert clinician, but they must also be skilled in delegation, supervision and the evaluation of subordinate staff’s activities. Nurse mangers are accountable not only to the patients whom they care for but also to those whom they supervise. The three most essential concepts for the nurse manager, supervisor, or team leader to concentrate on to prevent being found liable for negligence are delegation; appropriate nursing supervision; and scope and standards of practice.
From a legal perspective, the nurse working as a part of a multidisciplinary team is personally liable for his or her own actions. If that nurse is leading the team there is no liability for the actions of each individual team member, but there may be liability or accountability of the subordinate staff they are supervising or managing. The accountability of the nurse manger implies being responsible for the outcomes of care when one functions as the leader of the patient care team or charge nurse and he or she is held to a higher level of accountability.
Working to the Scope and Standards of Care
When a nurse’s care is being judged before a State Board of Nursing (SBON) or the courts they are held to the standard of care and the Scope of Practice set forth by the state and the area of specialty in which they practice.1 The law defines a standard of care in relation to each nursing task and the expectation is that any nurse who accepts the responsibility for a patients care will have the knowledge, skills, and experience to perform the task or role required of them to provide up to the legal standard. The nurse manager must be up to date on their understanding of their own state nurse practice act that defines the requirements for practicing nursing as well as the requirements for any subordinates he or she may be supervising or delegating nursing care to. Most SBON have revised and administrative rules and regulations governing nursing practice, codifying the legal accountability of the RN who makes assignments; delegates patient care tasks to other team members, and supervises subordinate staff. All RNs should be thoroughly familiar with the statutory language regarding delegation and supervision contained in their state nursing practice and act and the administrative rules and regulations in the state they practice in.2
In addition to making sure the nursing staff meets standards of care per their licensure they also have the primary responsibility for establishing and maintaining standards of care that the staff must follow.1 The nurse manager must make sure that the nursing standard described in the policy and procedure manuals are reasonable and that the staff knows and understands them. All nurses are responsible to make sure the facilities’ policies and procedures are up to date and current with national standards since any nurse will be held accountable to the standard of care regardless of the facility having an outdated policy and procedure as it is every nurse’s responsibility to obtain current continuing education to keep up to date on patient care standards. It is the nurse manager’s oversight and responsibility to assure that the manuals are available for all nurses assigned and that staff are up to date in review of the policies and that they are preforming procedures in accordance. The key to the manager’s functioning in this area is reasonableness. It is considered reasonable for a nursing supervisor to check periodically to make certain that procedures are being followed and that the nurses working in an area know the procedures used routinely.
Delegation
Delegation occurs when the nurse assigns another nurse or healthcare worker to perform patient care tasks. The nurse is delegating care tasks but remains accountable for the actions of that healthcare worker. Both the nurse and the staff delegated to can face malpractice or negligence claims should an injury occur to the patient. The nurse who is delegating has the obligation to know whether the healthcare worker has the skills necessary to safely perform the delegated patient care. The nurse must also verify that care was properly given to the patient. The National Council of State Boards of Nursing (NCSBN) published five rights of delegation for nursing managers:
1. Right task
2. Right circumstances
3. Right person
4. Right direction and communication
5. Right supervision and evaluation. 3
It is the nurse manager’s responsibility to determine on a day-to-day basis whether nurses are capable to perform the necessary procedures to provide care that meets standard. With that responsibility also comes assessing that nursing staff are delegating to assistive nursing staff within their scope of practice. A skilled team leader must be able to set priorities regarding the patient’s needs and know when to reassess the patient or personally intervene in the patient’s care based on periodic communication and assessment with the subordinate staff.4
Appropriate Supervision
Nurse managers are often seen as the primary problem solvers in the nursing facility or nursing unit of care. They will frequently be functioning as administrators and are instrumental in resolving conflict in addition to being responsible for staffing and arranging work schedules to ensure adequate patient care. They have supervisory duties when a patient has a deteriorating condition or when there is a need for patient advocacy and with this comes some additional potential legal liability.
SEE ALSO: Call to Embrace Nursing Ethics
A commonly asked question is “Do I risk losing my license if the unlicensed personal I supervise are negligent?” The answer is: “No.” Only the person who maintains the license can lose it and, any student, nursing assistant, or tech does not work under the protection of their license. The subordinate staff is working within the confines of the health care facility or business and is under the license of that particular facility and not of a specific nurse manager. The nurse manger has an obligation however, to ensure that that unlicensed personnel are not preforming functions that require nursing license and that they must also supervise and be sure that the tasks assigned are appropriately carried out. It is a nurse manger’s obligation to ensure that the tasks are performed correctly and that the unlicensed personnel do not perform functions that require a license and that they perform assigned functions in an appropriate manner.5
Another common area that a nurse manager may find they are liable for is failure to perform supervisory duties. Most hospitals have a chain-of-command policy that is used when emergency medical care is needed or when patient advocacy needs to take place. These policies usually involve the nurse manager and other nursing executive’s duties to take the concerns of the patient caregiver to the proper authorities to obtain appropriate medical care for the patient. In malpractice cases allegations of a failure to follow the chain-of-command policy often are made retrospectively, knowing the bad outcome and claiming that nurses had a responsibility to obtain additional medical care that would have prevented the patient’s injury.6
It is important that all nurses and staff know this policy and follow it as well as documenting application whenever there is concern for patient care or safety.
In conclusion, the nurse manager must ensure patient safety and efficient function of the unit with which comes an increased accountability. The RN who assumes the duties of a nurse management role such as charge nurse, supervisor, or unit manager must have a high level of clinical expertise and organizational skills. The supervision provided in this role must be constant, active and consistent with the nurse manager’s standard of care and standard of practice.
References
1. American Nurses Association. Nursing: Scope and Standards of Practice, 3rd ed. Silver Spring, MD: American Nurses Association; 2015.
2. White K M., and Scott ES. Revising the Scope and Standards for Nurse Administrators. Journal of Nursing Administration. 45(12): 598-599, December 2015.
3. National Council of State Boards of Nursing. (1997)The Five Rights of Delegation. Retrieved March 14, 2016 from https://www.ncsbn.org/fiverights.pdf
4. Fagan M. Techniques to improve patient safety in hospitals: what nurse administrators need to know. J Nurs Adm. 2012; 42(9): 426-430.
5. Cadiz DM, Truxillo DM, O’Neil C. Common risky behaviors checklist: a tool to assist nurse supervisors to assess unsafe practice. J Nurs Manag. 2015; 23(6): 794-802.
6. Kallas K. Profile of an excellent nurse manager: identifying and developing health care team leaders. Nurs Adm Q. 2014; 38(3): 261-268.
Karen Wilkinson is the owner of Wilkinson Legal Nurse Consulting in Seattle. She has over 30 years of experience as a nurse practitioner and is also a paralegal.
