A Deceptively Simple Phrase
Every area of expertise has its own words and phrases with meanings specific to that field. Sometimes, however, a term can have a different meaning than its users realize. The phrase “standard of care” is such a chameleon – its meaning changes depending on whether a health care provider is using the phrase or a lawyer is using it. And the difference can be significant if you are the nurse on the legal end of it, whether as an expert witness or a defendant in a suit.
For nurses, the phrase “standard of care” usually means something between “the way we do things around here” to “best practices” or what the Joint Commission or some other accrediting agency says is a standard. It sounds simple – until you look at the legal definition.
Black’s Law Dictionary defines it as “the average degree of skill, care, and diligence exercised by members of the same profession, practicing in the same or similar locality in light of the present state of medical and surgical science.” The American Nurses’ Association adds that the standard of care isn’t a guideline or policy but “the embodiment of collective knowledge for what is required of the average nurse and it sets the minimum criteria for proficiency.” The term you hear most often is “the reasonably prudent” nurse (or another practitioner).
All of which leaves us with at least three questions: 1) Who is this “reasonably prudent” or “average” professional? 2) Where can we find these “minimum” or “average” proficiencies? and 3) Who decides among competing standards? Add a fourth question – Why does it matter? – and you have the basis for hundreds of articles and book chapters, as well as the name of a central player in thousands of legal claims.
Starting with the “reasonably prudent professional,” you can’t go to the Bureau of Standards and point to an actual specimen for reference. The average reasonably prudent nurse is a hypothetical composite of all nurses. But there is more than one. It all depends on the level of education, years of experience, area of work, level of proficiency, type of facility, and geographic location (although this last is becoming less important as the profession moves to a national standard.)
The phrase “reasonably prudent” itself has its own definition in law dictionaries: “sagacious, circumspect in action, judicious, careful, sensible, cautious.” But nursing requires action – sometimes with only seconds to think. How do we combine prudence with our patients’ care needs?
Then there is the second question concerning standards. Even though the ANA says the standard of care isn’t a written document, reality says we must use written material to help us define and discuss the minimums we expect each nurse to achieve in a situation. Thus, in addition to our own knowledge, skills, experience, and commonsense, we draw from nurse practice acts, state laws and administrative codes, case law handed down by state and federal courts, policy statements and practice guidelines issued by professional organizations such as the ANA, goals and expectations published by the Joint Commission and other accrediting bodies, federal regulations such as those from the Centers for Medicare and Medicaid, authoritative texts, journals and treatises, and what “experts” say is the standard of care in specific situations. That’s a lot of potential sources.
Not surprisingly, we have conflict among sources and opinions from time to time. What’s important to remember, though, is that standards of care are the baseline – the minimum expected, not the gold standard.
So, who decides what the standard of care is? At the patient care level and the facility level, leaders, along with local professional schools, national organizations, published standards or consulting experts determine the required basic knowledge and expectations. They are manifest in the form of policies, procedures or care protocols. In a malpractice claim or suit, experts will give their opinions and the jury or judge will decide who is more credible – note that it isn’t always who is more correct.
Why does it matter? For patients, obviously, you want safe, evidence-based care. At the organizational level, you want standardization of processes and staff members who can think knowledgeably and critically, providing excellent care. At the national level, consistency and consensus based on research and education promote patient safety, decreased error rates and advances in the profession.
If we only look at the national medical error rate each year, we know that standards of care are essential to improved safety and care outcomes. Ultimately, it comes back to understanding the meaning of “standard of care” not just from the nursing perspective but from the legal perspective.
Whoever is involved in the discussion, be sure you are using the same definition. Standard of care is NOT the same as a duty to care. It also isn’t always the latest and greatest discovery or newest piece of equipment, although each of these may help shape your standard. A New York court has, I think, given us a little more workable concept. In Snow v State of New York, (98 AD2d 442, 447, 1983) the court said that one shouldn’t be faulted for “honest errors in judgment;” but if the professional’s judgement wasn’t based upon “intelligent reasoning or upon adequate examination,” and someone is harmed, there is a problem. Professional judgment is informed and shaped by our written standards of care. Be sure to know what your organization’s standards are and know that the phrase has a deeper meaning than you might think.
