NMBA OBA OSCE key terms

The range of roles, activities and responsibilities a nurse is educated, competent and authorised to perform, defined by legislation, registration standards and employer policy. Working outside it without supervision is unsafe and may be misconduct.

Being answerable for your own decisions, actions and omissions, including the consequences. A nurse cannot transfer accountability to a colleague, though tasks may be delegated; the delegating nurse remains responsible for the judgement to delegate.

Acting to protect and promote a person's rights, interests and preferences, especially when they cannot speak for themselves. It includes raising concerns about unsafe care, supporting informed decisions and ensuring interpreters or support persons are available.

The limits that keep the nurse-person relationship therapeutic rather than personal. Crossing them, for example through gifts, social media contact, secrecy or dual relationships, risks harm and exploitation and must be recognised and managed early.

A person's voluntary agreement to care or treatment after receiving adequate information about purpose, benefits, risks, alternatives and the right to refuse. Valid consent requires capacity, adequate disclosure and freedom from coercion, and must be documented.

The legal obligation to notify an authority about specified events, such as suspected child abuse, serious impairment of a health practitioner, or notifiable incidents causing serious harm. Nurses must know local triggers, timeframes and the correct recipient.

The legal and ethical obligation to take reasonable steps to avoid foreseeable harm to people in your care. It underpins assessment, escalation, safe systems and accurate documentation, and breach may support negligence claims.

Failure to provide the standard of care a reasonable practitioner would provide, causing harm. It requires a duty, a breach of that duty, causation and damage; poor documentation often weakens the nurse's defence.

An honest, timely discussion with a person and their family after a healthcare incident, covering what happened, the likely consequences, what will be done and how to complain or seek support. It is an ethical and often mandated process.

Care organised around the person's values, preferences, culture, goals and lived experience rather than around the task or the service. It involves shared decision-making, respect for dignity and tailoring communication and routines to the individual.

Purposeful verbal and non-verbal interaction that builds trust and supports the person's understanding and choices. Techniques include open questions, active listening, reflection, summarising and silence, while avoiding judgement, false reassurance and jargon.

Fully attending to a person's words, tone and body language, then confirming understanding through paraphrasing and summarising. It reduces missed concerns, supports accurate assessment and signals respect, particularly when the person is distressed or anxious.

Understanding and acknowledging another person's feelings and perspective without taking them on as your own. It is expressed through naming emotion, validating experience and offering presence, and it differs from sympathy and from agreeing with everything said.

A person's ability to obtain, understand and use health information to make decisions. Nurses adapt by using plain language, teach-back, chunking information, visual aids and interpreters, rather than assuming understanding from a nod.

A checking technique where the person explains in their own words how they will take a medicine or manage care. It reveals gaps in understanding and shifts responsibility for clarity to the nurse, rather than asking 'do you understand?'.

Care that recognises power differences, history and culture, and that the person experiences as respectful and free from discrimination. It requires reflection on your own biases and partnership with the person about what safe care means to them.

A person's ability at a given time to understand information relevant to a decision, weigh the consequences, retain it and communicate a choice. Capacity is decision-specific and presumed; it is assessed by the clinician proposing treatment, not by diagnosis alone.

A partnership in which the clinician explains options and evidence and the person contributes values and preferences to reach a joint plan. It respects autonomy, improves adherence and is documented with the chosen option and rationale.

A structured primary survey prioritising Airway, Breathing, Circulation, Disability and Exposure, with intervention and reassessment at each step. It ensures immediately life-threatening problems are found and treated before less urgent ones, and is repeated after any deterioration.

The cognitive process of gathering cues, interpreting them against knowledge, generating and testing hypotheses, then deciding on action and evaluating the outcome. It explains why a finding matters and guards against premature closure and anchoring bias.

Timely communication of deterioration or unmet need to a clinician with greater authority, using a structured format and explicit request for review. It includes knowing triggers, the chain of command and how to act when a response is inadequate.

A track-and-trigger tool scoring routinely measured observations such as respiratory rate, oxygen saturation, blood pressure, pulse, consciousness and temperature. Aggregate scores and single-parameter triggers guide monitoring frequency and escalation thresholds.

Worsening of a person's clinical state, often preceded by subtle changes in observations, behaviour, mobility or oral intake hours before an emergency. Recognising trends rather than isolated values allows earlier intervention and prevents cardiac arrest.

Death or serious harm resulting from failure to recognise, report or act on deterioration. It is associated with infrequent observation, poor documentation, hierarchy and task focus, and is reduced by structured rounding and assertive escalation.

Life-threatening organ dysfunction caused by a dysregulated response to infection. Suspicion arises from new confusion, raised respiratory rate, low blood pressure, fever or hypothermia, and requires urgent cultures, antibiotics and fluid resuscitation per protocol.

The checks of right person, right drug, right dose, right route and right time, now often extended to documentation, reason and response. They are verified at the point of administration using two identifiers and a current order.

A medicine carrying a heightened risk of serious harm when misused, such as insulin, anticoagulants, opioids, potassium concentrates and cytotoxic agents. It requires independent double-checks, clear labelling, standard concentrations and targeted monitoring.

A formal process of obtaining and verifying a complete list of a person's medicines and comparing it with current orders at admission, transfer and discharge. Discrepancies are resolved and communicated to prevent omissions, duplications and interactions.

Harm arising from a medicine, including errors in prescribing, dispensing, administering or monitoring, and expected side effects. Recognition requires reporting through the incident system and clinical review, not blame of an individual.

Routine infection-control measures applied to all people regardless of diagnosis: hand hygiene, gloves and gowns based on risk, safe sharps handling, respiratory etiquette, cleaning of equipment and correct waste segregation. They assume every body fluid may be infectious.

The World Health Organization's indications for hand hygiene: before touching a person, before a clean procedure, after body fluid exposure risk, after touching a person, and after touching their surroundings. Correct technique and timing reduce cross-transmission.

A set of practices that prevent micro-organisms entering a susceptible site during invasive procedures, such as wound care or intravenous access. It includes hand hygiene, sterile field, sterile gloves, and not touching key parts or key sites.

Additional precautions for specific pathogens, covering contact, droplet and airborne spread, used with standard precautions. They determine room type, ventilation, personal protective equipment, movement and visitor rules, and end when criteria are met.

Practices preventing needlestick and splash injury, including not recapping by hand, immediate disposal in a puncture-resistant container filled to the marked line, and safe positioning. Exposure requires immediate washing, reporting and post-exposure assessment.

A structured review of factors increasing fall likelihood, such as previous falls, medication, cognition, mobility, continence, vision and environment. It drives individualised strategies like bed height, footwear, supervision and toileting rounds, reassessed after change.

The likelihood of localised skin and tissue damage from pressure and shear, assessed with a validated scale plus skin inspection. Prevention includes repositioning, support surfaces, moisture management, nutrition and documenting skin condition each shift.

An acute, fluctuating disturbance of attention and awareness, often triggered by infection, pain, medicines, withdrawal or environment. It is a medical emergency and a deterioration marker, distinguished from dementia by its sudden onset and reversibility.

A structured communication framework: Identify, Situation, Background, Assessment, Recommendation. It ensures complete, concise transfer of information, invites the receiver to read back recommendations and reduces omissions at shift change or referral.

Recording assessments, interventions, responses and communication as soon as practicable after the event, with time, date, signature and objective language. Late or vague entries undermine continuity, legal defensibility and detection of deterioration trends.

A factual record of an adverse event or near miss submitted through the organisation's system for review and system improvement. It supplements, but never replaces, clinical documentation and should not carry blame or speculation.

Deliberate examination of your own actions, feelings and outcomes to learn and improve. Models such as Gibbs or Driscoll structure description, analysis, evaluation and an action plan, supporting continuing professional development and safer practice.

Ongoing learning that maintains and extends competence, including mandatory training, courses, peer review and reflective records. It is a registration requirement and should address identified gaps and the changing needs of the population served.