Report on Breaches of SOP in Nursing Practice
Some years back, most lawsuit cases in the medical practice involved doctors. However, the past few years have witnessed a striking rise in the rate of lawsuits that have been brought against nurses. This indicates the changed perception that nurses are not just seen as staff who execute doctors’ advice blindly, but they are seen as responsible medical personnel with full ownership of duties in patient care. It is, therefore, extremely relevant in context that nurses understand their roles fully and deliver them well to avoid legal scrutiny.
To help personnel of any organisation or institution have clarity of processes and operations, the Standard Operating Procedures / Standards of Practice (SOPs) came into place. These are formal instruction manuals to professionals, explaining how to execute their roles, in line with the vision of the organisation. Any deviation or breach of these standards of practice are serious issues, which when legally handled, may even lead to heavy penalties, dismissal from duty and imprisonment.
SOPs are crucial in any organisation, however, this article particularly explores the issue in the nursing context — what leads to breaches, what are the impacts of SOP violation in the nursing profession, how to prevent such breaches, etc. Various literature on this issue have been studied and used here to substantiate the thoughts laid down in this article.
Standard Operating Procedures / Standards of Practice
Why do we need to set standards? Why are SOPs necessary? The answer is simple: standardisation provides solution to repetitive tasks/problems across all disciplines. Many have attempted to define SOP — The US Environmental Protection Agency calls it “a set of written and detailed instructions that document a routine or repetitive activity followed by an organization to achieve uniformity of the performance of a specific function“; Vorster (2011) calls it “one of the most useful systems to streamline” business; Akyar (2012) defines it as “a process document that describes in detail the way that an operator should perform a given operation“. Simply put, it is a document that clearly indicates who is supposed to do what and how.
Amare (2012) makes a valid point that we often tend to think that SOPs are only pertinent to complex businesses and organisations, but in reality, standards of practice are important in all practices, more specifically in the medical industry that deals with careful processes and application of medicines and care. Adherence to SOPs is very critical in the medical practice because failure to meet the standards may result in reputation damage, injury to life and even death of patient. SOP breach is chosen as the topic of discussion for literature review as it is a crucial issue even for the nursing practice, given the current rise in malpractice lawsuits brought against nurses in recent times.
SOPs are established to guarantee that all personnel are delivering their tasks uniformly, which is necessary to get desired outcomes from the processes (Akyer, 2012). All nurses must also comply to the SOP requirements at all times to avoid being held up for a breach and subsequent complexities.
Malpractice & Its Import for Nurses
According to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), malpractice is defined as “improper or unethical conduct or unreasonable lack of skill by a holder of a professional or official position; often applied to physicians, dentists, lawyers, and public officers to denote negligent or unskillful performance of duties when professional skills are obligatory. Malpractice is a cause of action for which damages are allowed.” For nurses, malpractice usually means negligence (Ashley, 2003), which is defined as an act that a reasonably prudent individual wouldn’t do in a situation similar to the one mentioned in evidence (Black, 1998). Negligence in nursing or nursing malpractice, therefore, means lack of usual reasonable patient care.
The general public’s awareness of their legal rights in healthcare is steadily on the rise, which is one reason why there is an increase in the number of medical malpractice lawsuits (Malarvizhi & Samson, 2015). In sharp contrast is their empirical finding that a large 44.5% of the nurses they surveyed had poor knowledge on the legal consequences of negligence. This is an alarming percentage, given the amount of criticality their profession holds. Not only are they expected to be aware of the standards of practice they are required to follow, but also the legal consequences of the failure to do so.
Forms of Nursing Negligence
According to a study by the Physicians Insurer’s Association of America (1993), 30% of all malpractice cases in the medical industry comprised injuries related to medication. But as Aiken & Catalano (1994) mentioned, the nurses are fortunate that a small percentage of nursing errors actually cause injury. And of these, the number of injured patients legally alleging a negligence is even less. However, that should not be a point of relief. Although Giordano (2003) concludes that the chance for nurses to be charged a malpractice lawsuit is relatively less, he goes on to put in a word of caution as well — “the risk clearly is increasing” with increased patient demands from nurses and growing consumer awareness of healthcare rights.
The common types of nursing negligence that lead to litigation are incorrect drug administered and in incorrect dose, inappropriate way of administering a medicine, improper dose of the medicine given, failing to judge for toxicity and side-effects of a medicine (Giordano, 2003); or even failure to document (Croke, 2003). Valid nursing negligence issues could also be failing to report adequately about the patient’s condition to the doctor, or insufficient assessment of the patient, inadequate nursing care, medication-related mistakes, wrong use of medical equipment, etc (Miller-Slade, 1997; Campazzi, 1980). Another significant malpractice issue is lack of infection control /proper hygiene maintenance (handwash services). According to Rokosh (2015), hands of healthcare professionals are the commonest medium for transmitting infective pathogens, and conscious handwashing can stop the spread of infection.
A healthcare-associated infection (HAI) survey conducted by the Centers for Disease Control and Prevention found that 1 out of 25 patients has an HAI on any given day (Magill, et al., 2014). In 2011, as per Magill, et al. (2014), there were about 721,800 HAIs estimated across acute care hospitals in the US. Of these, approximately 75,000 patients with HAI died in the hospitals.
In the light of these findings and observations, it is true that there could be breaches in following standard care and hence, nurses should pay more attention to SOP compliance while on duty, to save the image of the hospital they represent and also the damages/compensation of litigation, if any.
The Legal Aspect
A negligence lawsuit ensues against a nurse when a patient alleges that he or she was injured under that nurse’s care while she was on duty (Ashley, 2003). However, the injury needs to be proved by the plaintiff. It is the plaintiff’s responsibility to prove the following (Morales, 2012):
- The nurse had a duty to the plaintiff.
- There was a breach of duty or standards of practice.
- There was an injury due to the breach.
- The breach caused the damage to the plaintiff.
The plaintiff must also define what the right standard of care is (Ashley, 2003). Although a growing number of nurses are seen as defendants in malpractice lawsuits as per the National Practitioner Data Bank (NPDB) (Croke, 2003), all unfortunate incidents in the medical practice are not due to malpractice (Giordano, 2003). Since the nursing profession involves certain amount of clinical judgement, all medical injuries cannot be a result of flawed service, nursing negligence or breach of standards of care. It must satisfy the above conditions to qualify for filing a lawsuit and further probe.
Strategies to Manage Nursing Negligence
In order to manage any issue, it is important to understand the causes behind it. Why does negligence happen in nursing care? Why are nursing malpractice lawsuits growing? According to Croke (2003), the following could be the probable reasons:
- Early and untimely discharge of patients often relate to nursing negligence as it means lack of proper assessment of patient’s condition and appropriate referrals.
- Hospital downsizing and staff shortage also lead to work pressure and chances of error.
- Well-informed consumers
- Sometimes nurses are challenged by technological advancement in terms of medical equipment and their safe use.
- When professional nurses delegate responsibilities to unlicensed employees, chances of error increase (also mentioned by Roussel, 2011).
- The nature of nursing practice has undergone a sea-change in terms of skill and knowledge demand from the nurses. They have more autonomy, role and responsibility these days. Hence, greater liability and risk of mistakes.
There could be more reasons behind nursing negligence and resulting lawsuits, but the good side is that there are also parallel efforts and strategies to manage such issues. Some of the commonest strategies are through hospital staff education, patient education and more.
Ethics code or standards of practice in nursing often tend to exist in theory, than in practice because of complacency (or may be sheer ignorance) of the professionals. It is precisely why lapses in patient care happen and nurses are sued. The following can be reiterated to nurses from time to time:
- Keep the communication channel open, honest and timely both with the doctors and the patient’s family. Guido (2001) held that patients are unlikely to sue if they feel the nurse had been involved, caring and professional. Rokosh (2015) suggests the situation, background, assessment and recommendation (SBAR) technique to better communication between doctors and nurses.
- Nurses must be made aware of legal principles, hospital policies and procedures through education classes and in-service programs.
- They must practice within limits of professional licensure (Croke, 2003).
- They must be upskilled and trained to use advanced medical equipment safely and correctly. That is the hospital’s responsibility to train them (Rokosh, 2015).
- They must be trained in: (i) appropriate medication administration, (ii) infection control and (iii) measurement techniques (question formation, data collection, data interpretation, reporting, etc).
- They must participate in ongoing quality programs, performance and safety improvement initiatives.
In healthcare, it is sometimes essential to involve both the patient and his family to determine the patient-care plan. Patient education is important for self-care and self-management (MacLean, 2010) and it is the doctors’ role to educate them about their condition, what to expect and what not to. Patient education is also a patient’s right. The Patient Education Institute summarises the benefits of patient education as:
- It better prepares the patient and the family to cope with the health situation.
- It gives them better visibility of the diagnoses and treatment options. Naturally, they are better positioned to take decisions related to the care.
- Patients tend to be more agreeable to the care plan set for them.
- It facilitates recovery as the patient cooperates.
- Patient confidence increases and helps his/her self-care. Therefore, treatment becomes easy and less complicated.
In light of the literature review on the various aspects of nursing and nursing standard breaches, it seems that compliance to standards, codes or policies in the medical profession has been slipping on several occasions, increasing malpractice cases over recent years. Reasons are numerous and multi-faceted for such lapses, however, efforts are in place too to prevent breaches in standards of practice. Staff education and patient education are indeed vital ways to improve the situation and lower breach case counts. Apart from that, there should also be a monitoring body in every hospital to check compliance periodically. Some hospitals have nursing quality and PI plans to keep tab on patient care standards, some have also initiated quality learning systems for its staff and patients. But these initiatives need to expand across hospitals, states and countries with consistency in practical use. Although it is true that all unfortunate events in medical history are not malpractices and cases of nursing negligence, it is also undeniable that there have been breaches in SOP, which are uncalled for in a profession as critical and sensitive as nursing. SOP-breach is extremely relevant an issue that nurses need to be cognizant of.
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