Our Nursing Code of Ethics includes a provision that nurses have authority, accountability, and responsibility for nursing practice; that they make decisions and take actions consistent with the obligation to promote health and to provide optimal care. Our discussion is based upon the latest ANA Code of Ethics with Interpretive statements.

According to the American Nurses Association’s Code of Ethics, Provision Four, nurses are accountable for their own nursing practice and they bear the primary responsibility for the nursing care their patients receive.  

What is nursing practice?  It includes independent nursing care, such as the obtaining of vital signs and the completion of an assessment; care provided in response to an order by a healthcare provider; the coordination of patient  care, such as the scheduling of an outside appointment; the evaluation of nursing interventions to determine whether the nursing plan is effective; delegation of nursing interventions; and other nursing responsibilities like teaching, administration and research.  In every role correctional nurses have vested authority to perform the function.  They are always accountable  and responsible for the quality of their nursing practice.  Thus, correctional nurses must use judgment when accepting responsibilities, consulting with a provider, and assigning activities to other members of the care team at the facility.  

Correctional nurses must always comply with and adhere to state nurse practice acts (and scopes of practice); regulations, standards of care applicable to the correctional environment, including the Correctional Nursing: Scope and Standards of Practice; and the ANA’s Code of Ethics for Nurses.  It is important to note that the ANA specifies that the nurse is accountable for decisions made and actions taken in the course of nursing practice, and the systems and technologies used at the facility are not a replacement for the nurse’s knowledge and skill.  For example, if your site has an electronic health record that automatically enrolls a patient in a withdrawal protocol and something was not entered correctly to “flag” the system (or the system was down, or…) and the patient is not placed on CIWA monitoring as they should, the responsibility for monitoring the patient is still the nurse’s.  This has potentially great impact on our reliance on the technologies, especially if there are no checks and balances in place to ensure that patients are correctly identified. 

Nurses are accountable for their own judgments, decisions and actions

Nurses always are accountable for their own judgments, decisions and actions.  They must accept or reject specific duties and assignments based upon their education, knowledge, experience and competence.  Nurses who do not have a direct patient care role still have obligations to the patients, and they share the responsibility for patient care with the nurses they supervise and teach.  ANA cautions that nurses must not engage in practices that are prohibited by law, or delegate activities to others who are prohibited by their state nurse practice acts.  Correctional Nurses must develop review processes to keep patients safe, and to protect nurses, colleagues and the environment, including peer review, staffing plans, credentialling processes and quality improvement and research initiatives.  

In addition, correctional nurses are responsible to assess their own competence, and determine whether the task being asked of them is one in which they are competent.  If there is any question about their ability or the legality of the nurse to perform the function, then the nurse must consult and collaborate with another qualified nurse or the provider.  Organizations should assess their nurses’ learning needs, develop learning outcomes, and evaluate the teaching effectiveness once conducted to ensure their nurses’ competence.  This is an ongoing endeavor.

Assignment, Delegation of Duty

Lastly, the ANA Code of Ethics clearly states that the nurse is accountable and responsible for the assignment and delegation of nursing activities.  Delegation is always done in congruence with state practice acts, organizational policies and procedures and nursing standards of practice.  Provision Four also mandates that the delegating nurse must make a reasonable effort to assess individual competency when delegating nursing activities.  This assessment includes the evaluation of the knowledge, skill, and experience of the individual to whom the care is assigned or delegated; the complexity of the tasks; and the nursing care needs of the patient. In other  words, the correctional nurse assigning a task to another healthcare staff member is not relieved of the responsibility of that task because he/she/they delegated it to another.  In addition, nurses delegating a duty have the obligation to monitor and evaluate the quality and the outcomes of care provided by the person to whom the task was delegated.  Provision Four states that nurses may not delegate responsibilities such as assessment and evaluation, but they may delegate selected interventions according to state nurse practice acts. Employer policies or directives do not relieve the nurse of responsibility for making assignments or delegation decisions. 

Nurse Managers and Administrators

Nurse managers and administrators also have responsibility for a culture that supports and facilitates appropriate assignment and delegation.  In the correctional environment, this includes an adequate and appropriate orientation; verification of licensure, certification, continuing education, and competency; adequate staffing to provide safe patient care; and policies that protect both the patient and the nurse from inappropriate assignment or delegation of nursing responsibilities, activities, or tasks.  Open communication should be fostered that facilitates healthcare staff sharing concerns about assignments and their qualifications for that assignment, to include the ability of nursing staff to refuse an assignment without reprisal, if they feel they do not have the required skill. 

Provision Four solidifies that the nurse is responsible for his/her/their own practice, which must be conducted always within the bounds of the state nurse practice act and laws, and according to the nurse’s education, training and skills. Delegation to others may be done, but the nurse must always remember that delegation does not alleviate the nurse’s obligation to the patient to provide safe and competent care. Nurses who have concerns about an assignment or task for which they do not feel they are adequately trained should feel free, at all times, to discuss those concerns with supervision, and refuse the assignment, if necessary, to ensure safe patient care.

The National Commission on Correctional Health Care has a WHITE PAPER about nursing authority, responsibility and delegation that you might find interesting.

What are your thoughts about Correctional Nursing, practice authority, and delegation? Share your thoughts in the comments section of this post.