Page 3 Management of Care Study Guide for the NCLEX-RN® exam

As a nurse, you are responsible for understanding the legal limitations and scope of practice of your nursing license. Many of these parameters are mandated by both federal and state laws, as well as by general guidelines such as the Nurse Practice Acts (NPAs). Each state will have a state Board of Nursing that will serve as your credentialing body and source of information on the confines of laws applicable to the state in which you practice.


Negligence is an unintentional act or failure to act which brings harm to a patient. It involves the failure to act in the same way that a reasonable person would, given the same set of circumstances. Failure to give a medication or give it in a timely manner could be examples of negligence if the patient has an adverse reaction as a consequence. In each case, the nurse exhibits a breach of duty of care that is an essential component of negligence.


Malpractice differs from negligence in that it has the element of intent. Often, the states set the requirements for malpractice, so they can vary. In general, malpractice occurs when a nurse fails to competently perform his or her duties and the patient suffers harm as a result. Examples could be giving the wrong medication to the wrong patient or giving a medication in a dosage other than what was ordered.

A Nurse’s Role

The nurse is responsible for proper and timely care of patients. Any incorrect or inappropriate actions or the lack of action (as set by the standard of care) could result in legal action against the nurse if the patient suffers harm as a result. Be familiar with your legal rights and responsibilities.

Response to legal issues—You must be able to identify and respond appropriately to legal issues relating to patient care. Examples include a patient’s refusal of care and privacy rights of minors.

Seeking assistance—You must be able to identify tasks and assignments that you are not qualified to perform and seek help or guidance when necessary.

Patient valuables—Your facility or practice will have specific guidelines that you must know and follow with regard to handling valuables.

Patient and staff education—Participating in required and elective education events helps ensure you understand and are prepared to respond appropriately to potential legal and ethical issues.

Regulations for reporting—Certain health conditions (communicable disease, dog bites, etc.) have both state and federal regulations that must be followed. You also need to be familiar with regulations that apply to you as a mandated reporter of suspected child abuse and other crimes.

Unsafe practice reporting—When you’ve witnessed unsafe practices of other healthcare personnel, you are responsible for reporting it to the appropriate overseeing agency, both at your facility and to your state’s credentialing board.

Intervention during unsafe practices—To keep patients from harm, you must identify and intervene appropriately when you witness potentially unsafe actions of other healthcare team members.

Organ Donation

Organ donation is the process of harvesting on organ or tissue from one person and transplanting it on or into another. Internal organs, skin, bone and bone marrow, and corneas may all be donated/transplanted. While many organ donations take place after the donor is deceased, some are done with a living donor (e.g., kidney, bone marrow).

Nurse Roles

Specialized nurses, called procurement nurses, are involved in the care of organ donation/transplantation patients. Also, nurses who counsel patients and their families on the specifics of organ donation must have special training under federal law. As an entry-level nurse, your involvement in the process will likely be ensuring that your patients over the age of 18 have copies of their advance directives in the medical record.

Advance Directives and Donation

Advance directives are legal documents that specify the patient’s wishes if he or she should become incapacitated and not able to express them for him or herself. The patient’s wishes for organ donation, specifically, should be obtained and documented within the medical record if the patient is legally able to provide this information.

Performance Improvement

Different medical institutions each have specific definitions of quality, but generally the term refers to meeting or exceeding the patient’s expectations, meeting or exceeding the standards for care, and achieving the planned outcomes for all patients. Quality improvement refers to the process of identifying and improving quality issues with regard to nursing care. This may include:

TQMTotal Quality Management: a long-term management approach to success that is centered on patient satisfaction

CQIContinuous Quality Improvement: a management approach that is centered on ongoing evaluation and improvement of the processes that lead to success

Evidence-based decision making—This approach focuses on adjusting policies and processes according to the most recent research evidence.

Quality management plan and benchmarks— This approach uses performance measures to adjust processes accordingly. Benchmarks are points of comparison that can be used to identify problems in the process. This approach encourages competition as it typically seeks to identify the best practices at the best cost.

Reporting issues— Nurses play a critical role in quality improvement. By reporting patient care problems or issues to the appropriate personnel, you ensure proper management evaluation of why they occur and facilitate correction.

Resources— You may also serve as a quality improvement resource for your institution, practice, or agency. You may be a source of data collection or participate on a group or team that is involved in the performance improvement process. You may also be asked to evaluate the impact of procedural or process changes to your nursing practice.

Nurse-sensitive indicators— Nurse-sensitive indicators are measurements of patient care that are directly impacted by nursing interventions. Examples of these are skin breakdown (decubiti), falls, and the use of restraints.


As you care for your patients, you will often play a role in helping to coordinate care with other healthcare providers or community agencies.This may be as simple as recommending a particular provider (dietician, physical therapist, wound care center), but it may also require you to obtain prior authorization for your patients via their insurance company. Your job is to appropriately assess your patient’s needs and then assist him or her in the referral process to get the care needed. You will also be responsible for providing the appropriate documentation to the provider or facility your patient has been referred to (i.e., referral form or copy of the medical record, etc.).