The autonomy of the nurse in opposition to the medical act: when, how and why
The nurse autonomously, it moves in a sphere that faces towards a neighboring terrain, that of medical practice. But in some cases it may seem that the executor (nurse) overrides and replaces the prescriber (doctor) contrasting the decision until it is blocked and not executed. In truth, responsible autonomy always guides the nurse to decide by virtue of the position of guarantee to protect good health.
Why the nurse in some cases, can and must refuse to follow up on the prescription? In doing so, does it cross the medical border? How and when?
The beginning of nursing autonomy
The autonomy of the nurse twenty years after Law 251/2000 it represents a new world still unexplored. The ability to act in a purely professional sphere is not clear to many, but it is not a matter of choice. A new investiture of responsibility travels hand in hand and always with attached charges, which indicates the path of “know-how” and “know-how”.
The nurse is no longer “auxiliary”
Law 42/1999, abolishing the adjective “auxiliary” which from 1934 accompanied the element of “health profession”, actually pushes towards theautonomy of the nurse conceptual that will be defined by further legislative provisions. From this moment, in fact, no health profession is subordinate to another. The limit competence is given by the professional profile (and no longer by the job description), by the university and post-basic training system, by the code of ethics.
This baggage to draw on with regard to competence, responsibility and function is always at hand and essential.
The role of autonomy in the health professions
Also defined as the “Law of nursing management”, L.251 / 2000 represented, in a context of the paradigm of the profession, a springboard towards the autonomy of the nurse.
For the first time the law made explicit the concept of professional autonomy linked to the scope of decision-making discretion, always within the limits of nursing skills. The departure towards a terrain of conquest that opened up unknown but fruitful for the professional, immediately impacted a soul still relegated (by someone else’s merit) and tied (through his own fault) to reminiscences of the past.
In fact, not everyone was ready to abandon an ideal of a happy island, in which the nurse knowingly and with tacit assent allowed himself to be used to achieve a healing purpose. By assuming only a marginal auxiliary role, it showed a senseless fear of the change that could be seen on the horizon.
Already from the 80s this dream of emancipation was accompanied by pushes that tended to build the definitive long professional bridge towards the mainland, that is, towards the world of expression ofhealth act actual. A bridge leading toautonomy of the nurse with the necessary role of protagonist it had become compelling and no longer extendable.
As in a race to conquer space, the unknown, a new planet that awaits only the first footprint, to open up and prove friendly and resplendent, so the nursing, midwifery, health, rehabilitation and prevention techniques professions were launched towards the future of the healthcare context. At last they could cross the bridge carrying their own professional autonomy.
The border war between the doctor and the nurse
With the advent of the concepts of autonomy and responsibility of the health professions The debate between the nurse and the doctor about the skills that defined the personal field of activity immediately started. In fact, the sectors of the diagnostic-therapeutic and care pathways were touched. The fact that in a modern concept of public health multiprofessionality was put at the center in an equally divided area, immediately contributed to increasing resentments not yet fully understood.
When and how can the nurse independently disregard a medical prescription?
The concept of autonomy it changes in some ways, while remaining tied to a positive sense of decision-making that falls within the competences of the nurse. In this specific case, the commission and the omission of a fact are found to be on the same level and to coexist, almost in antinomy (contradictory relationship, decides not to decide). In other words, the nurse who must perform the administration, decides to omit the procedure (not to carry it out), to protect the patient, being the professional of the warranty position. Why can he do it?
Having the duty to protect and supervise the good health of the patient, he realizes at that moment that with the omission of the administration he can avoid damage, he can save the life of the “patient”.
With the L.251 / 2000 the autonomy scenario opens up to the nurse. According to art.1 the functions mentioned in DM 739/94 can all be carried out independently, i.e. personal initiative, with the exception of one, which concerns a prescription. Only the doctor can prescribe and only the nurse can administer.
But the nurse now represents a new point of reference as regards the protection of the patient’s health, he can therefore assert his “arbitrariness” with accurate forms of behavior.
So it can, and is now obliged by several jurisprudential pronouncements and by virtue of the completely independent guarantee position with respect to the doctor (Cass. section IV, n. 9638/2000; section IV, n. 2541/2015, section IV, n. 24573/2011), oppose what has been prescribed.
Autonomy of the nurse in prescription errors
How many times already for the mere fact that “we put the nose” only out of curiosity in a medical therapy, just to understand something we (since we now knew the life, death and miracles of that patient), it was pointed out to us in all ways to think about our facts and stay in our place? In many cases the doctor’s glare has already been more than oloquent.
What is certain is that the nurse cannot oppose a medical choice regarding therapy, but must be able to have his say on any errors noted, and also on the adequacy or relevance of the therapy.
In fact, the act of administration cannot be considered a mechanistic act, but enters into an area of collaboration with the medical figure.
If the nurse notices errors:
- incompatibility between drugs;
- various errors (dosage, wrong route of administration, wrong infusion rate, etc.);
- incompatibility between pathology and prescribed drug;
- allergies noted in the file or known
he is obliged immediately to stop the administration and notify the doctor who will reevaluate the due. in conclusion
“nell’autonomy of drug administration, the nurse must always make an assessment of what he is giving “(L. Benci 2019),
being the guarantor of the correct procedure for administering the drugs.
A ruling by the Supreme Court (Civil Section III, n. 7106/2016), represents a milestone in terms of professional nursing responsibility. Pfor the first time in a sentence, it is established that it becomes the nurse’s job to intervene directly on the “incorrect or incomplete” prescription not really disregarding it, but integrating it and modifying it to bring it back to the protocols in use.
The doctor’s defense tried to counter and focus more on the doctor-nurse co-responsibility and not on the exclusive responsibility (his own), reiterating that in any case the nurse had to dilute (having mistakenly omitted the doctor).
Therefore iIn case of incomplete, incorrect or insufficient prescription, it is the duty of the nurse to intervene interlocutory and, where appropriate (even)
supplement the medical prescription.
Autonomy of the nurse in the changed clinical conditions of the patient
Starting from the guarantee position, it makes it possible for us to understand the specificity of the nurse’s autonomy. The Cassation (Pen. Section IV, n. 5/2018) has identified the foundation of this virtue, which derives from thesolidarity obligation imposed by Articles 2 and 32 of the Constitution: “right inindependent professionalism of the nurse as a person who performs an essential precautionary task in safeguarding the patient’s health … which today must be considered no longer an auxiliary to the doctor, but a health professional “. In the case he condemned the nurses who, having not recognized the aggravation of a clinical situation, did not notify the doctor on call. He also stressed that
“the nurse has a specific guarantee position towards the patient which is completely independent from that of the doctor “.
It is therefore easy to understand how the “armed” nurse of the concept of responsible autonomy is also required to abstain. autonomy nurse suggests that he should do what the doctor has prescribed when he realizes that the patient’s clinical condition has changed. In fact, that doctor’s prescription had been defined / resulted from the specific clinical conditions of the case.
The timeline in the autonomy process
When the doctor has carried out his physical examination at a point, which we could define as “X” or “0”, ie the moment from which the whole chain of events started:
- the physician on physical examination realizes, evaluates, certifies a given condition of the patient. It prescribes a drug always referred to the condition evaluated at the moment “0”.
- The nurse takes note of the prescription and endeavors to carry it out. At the same time he becomes aware of changes in clinical conditions (vital parameters) by applying his own nursing diagnosis. Refrains from administration, does not carry out a prescription. Notify the doctor of the change in the patient’s hemodynamic structure in order to reassess the new condition with an objective examination and reformulate the prescription.
- The doctor re-evaluates the new condition of the patient and issues a new diagnosis with a new prescription to the nurse.
Conclusions
The virtue of responsible autonomy must guide the nurse in making targeted choices towards the protection of good health, also by contrasting in a suitable and widely indicated way, a medical decision. This virtuous concept lies in the guarantee position, as is the case for the doctor and other healthcare professionals, but specific and individual.
Forensic Legal Nurse Giovanni Trianni
Sources:
- Rodriguez D., Aprile A., Forensic medicine for nurses, Carocci Faber, Rome 2015;
- Chiapusso B., Del Sordo S., Genovese U., Magon G., Steffano A., Vercesi L., The professional responsibility of the nurse and his insurance protection, Maggioli, Santarcangelo di Romagna, 2014;
- Red. Nine from Florence, Drug therapies: responsibility is interdisciplinary, Interview with the jurist Luca Benci, following a sentence of the Cassation, Nine from Florence, 2019;
- http://www.salvisjuribus.it/lautonomia-infermieristica-fonte-di-nuove-responsabilita-penali/
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