SNLE key terms

The range of duties, actions, and responsibilities a nurse is legally and professionally permitted to perform, set by state law, licensing boards, and employer policy, and limited by the nurse's education and competence.

Authoritative statements that describe the expected level of care and professional performance for nurses, used to judge whether nursing actions were reasonable and appropriate in a given situation.

The degree of care and skill that a reasonably prudent nurse with similar training would provide in similar circumstances; it is the benchmark used in negligence claims to evaluate nursing conduct.

Being answerable for one's own decisions, actions, and outcomes, including the duty to explain them and to accept consequences rather than shifting blame to others.

A state statute that establishes the legal authority for nursing practice, creates the board of nursing, defines licensure requirements, and sets the scope of practice for each nursing role.

The state agency created by the Nurse Practice Act that issues licenses, interprets scope-of-practice rules, investigates complaints, and imposes discipline on nurses who violate the law.

The legal authorization granted by a state board that permits a person to practice nursing, obtained by meeting education, examination, and character requirements and maintained through renewal.

An agreement among participating states that allows a nurse holding a multistate license in a home state to practice in other member states without obtaining separate licenses.

Required coursework or learning activities a nurse must complete within a renewal period to keep a license current and maintain up-to-date knowledge and skills.

Having the knowledge, skills, judgment, and attitudes needed to perform a task or role safely and effectively, demonstrated in actual practice rather than assumed from a credential alone.

Failure to provide the care a reasonably prudent nurse would provide, resulting in harm; it requires a duty, a breach of that duty, causation, and actual damages.

The legal obligation a nurse owes to patients to act with reasonable skill and caution, arising once a professional relationship is established.

Professional negligence by a nurse or other clinician in which substandard care causes injury to a patient, often evaluated against expert testimony about accepted practice.

A patient's voluntary agreement to a procedure after receiving and understanding information about its purpose, risks, benefits, and alternatives; the provider obtains consent and the nurse verifies and witnesses it.

Acting to protect and promote a patient's rights, safety, and preferences, including speaking up when care is unsafe or when the patient cannot speak for themselves.

The ethical principle that recognizes a patient's right to make informed decisions about their own care, consistent with their values, even when providers disagree.

The ethical principle of acting to benefit the patient and promote good, balancing potential benefits against risks when choosing interventions.

The ethical principle of avoiding harm or the risk of harm; it underlies duties such as safe medication administration and reporting unsafe conditions.

The ethical principle of fairness, requiring that patients receive equitable treatment and access to care without discrimination based on personal characteristics or ability to pay.

The experience of knowing the ethically appropriate action but being constrained from taking it by institutional rules, hierarchy, or other barriers, often causing frustration and burnout.

A situation in which two or more ethical principles conflict and any choice requires sacrificing something of value, so the nurse must reason through options rather than apply a simple rule.

The limits that keep the nurse-patient relationship therapeutic and focused on the patient's needs, prohibiting personal, financial, or romantic involvement that could exploit the relationship.

The duty to protect a patient's private health information from unauthorized disclosure, sharing it only with those who need it for care or as permitted or required by law.

A federal law that sets national standards for protecting identifiable health information and gives patients rights over its use, disclosure, and access, with penalties for violations.

Individually identifiable health data created or held by a covered entity, including names, dates, and medical details, which may be shared only under privacy rule conditions.

The entitlements patients hold in care settings, such as privacy, informed consent, respectful treatment, access to records, and the ability to refuse treatment.

The written or electronic record of nursing assessments, interventions, and patient responses, created contemporaneously and accurately to support care, communication, and legal accountability.

A note added to the record after the time of the event, clearly labeled with the actual date and time of writing and the time of the original event, without altering earlier entries.

Knowingly entering false, incomplete, or backdated information in a patient record, or altering another's entry, which is a serious legal and professional violation.

The documented, unbroken record of who handled an item such as a specimen or a suspected tampered medication, from collection through transfer, preserving its evidentiary value.

An internal document recording an unexpected event or near miss for quality review; it supports safety improvement and is generally not placed in the patient's chart.

An event that could have caused harm but did not reach the patient, reported so that underlying system weaknesses can be identified and corrected before injury occurs.

A structured team method for investigating a serious adverse event to identify the underlying system failures that contributed to it and to design preventive changes.

A systematic, data-driven approach to measuring care processes and outcomes and testing changes that reduce errors and improve patient results over time.

The discipline of preventing avoidable harm during care through practices such as hand hygiene, verification steps, error reporting, and attention to system design.

The transfer of a specific nursing task to another person while the nurse retains accountability for the decision to delegate and for the quality of the outcome.

The ongoing process of monitoring a delegated task, providing guidance and feedback, and intervening when needed to ensure the task is performed safely and correctly.

The distribution of work to staff based on their role, competence, and the patient's needs, distinguished from delegation because it transfers tasks within a role rather than across roles.

Purposeful, patient-centered interaction using active listening, open questions, empathy, and clarification to build trust and support the patient's understanding and decisions.

Fully attending to a patient's message, including tone and nonverbal cues, and reflecting or summarizing it to confirm understanding and convey respect.

The transfer of patient information and responsibility between caregivers using a structured format so that critical details are communicated completely and without omission.