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Pharmacy Technician Schools In Illinois

One of the accepted hallmarks of a profession is the possession of a unique body of knowledge. A recent Illinois Supreme Court case finally has given judicial recognition to nurses' long-time assertion that nursing is an independent profession with a unique body of knowledge and not simply a subcategory of medicine.

Before this case, judicial decisions tended to reflect society's confusion about nursing's relationship to medicine. (1) Judges uniformly allowed physician testimony on nursing standards, even when challenged. Sometimes they did so with complete confidence (eg, "Surely a qualified doctor would know what was standard procedure for nurses to follow." Goff v Doctor's General Hospital, 166 CA2d 314, 319 [1958]). At other times, especially recently, courts have been more ambivalent in their support of physician testimony about nursing standards. Sometimes they have recognized that the physician may not be the best possible witness but have allowed physician testimony because "all areas of medical expertise within the knowledge of nurses are also within the knowledge of medical doctors" (Taylor v Spencer Hospital, 292 A2 449, 452-452 [Pa Super 1972]).

Even more recently, courts have allowed physicians to testify about nursing standards but only after they have established some foundation as to how the physicians came to possess their expertise related to nursing standards. For example, in Logsdon v Miller (Tex App LEXIS 2055 [unpublished] 2002), the court was willing to accept physician testimony about nursing standards but only if the physician described how he or she was familiar with these standards. The court was not willing to assume, as had previously been the case, that all physicians know about all nursing standards.

SULLIVAN V EDWARD HOSPITAL

In 2004, a state supreme court held in Sullivan v Edward Hospital (WL228956 [Ill 2004]) that a physician is not qualified to testify regarding the standard of care for the nursing profession. The 74-year-old plaintiff in the case had suffered a stroke in March 1995, which caused partial paralysis to his right side and impaired his ability to walk independently. He also could not speak but could understand and would respond with physical gestures.

In November 1997, he was admitted to a hospital for treatment of a urinary tract infection. On admission, he was assessed as a Level II fall risk because of his partial paralysis. The evening after his admission, he tried to get out of bed on three occasions, even though all the bedside rails were up and despite the nurse's assessment that he was alert and had understood her instructions to stay in bed on the first two occasions.

After his third failure to follow instructions, the nurse asked the attending physician to order a vest restraint. The patient appeared to be agitated, however, and the treating physician was concerned that a vest restraint would cause more agitation. Instead, the physician ordered lorazepam to calm the patient and help him sleep. He prescribed a small initial dose--the precise dosage is not specified in the case report--with more to be administered if the nurse deemed it was necessary.

The nurse administered 1 mg of lorazepam at 10 PM. Between 10 PM and midnight, the nurse and a nurses' aide checked on the patient approximately every half hour. He was sleeping at each check. At approximately 12:05 AM, a nurse's aide noted he appeared to be sleeping. At 12:10 AM, a monitor technician heard a noise from the patient's room and informed the nurse. The nurse found the patient on the floor, his head bleeding from a cut above the left eye. The patient was found to have a subdural hematoma caused by the fall. He later sued, alleging the nurse and the treating physician had failed to properly monitor, medicate, and restrain him to prevent the fall.

At trial, the plaintiff attempted to establish the negligence of the nurse. He called a board certified internist who had experience in observing and working with physicians and nurses in the area of patient fall protection. The internist testified that the nurse had failed to adhere to proper nursing procedures. After the physician denied the request to order a vest restraint, the nurse failed to communicate her concerns that the patient would get out of bed up the nursing chain of command. She also failed to provide alternatives to the vest restraint, such as having someone sit in the room or moving the patient to an area where he could be supervised constantly.

At the close of the plaintiff's case, the trial court judge struck the internist's expert testimony (ie, he would not allow the jury to consider it) on the grounds that "a physician is incompetent to testify to the standard of care placed upon a licensed nurse" (Id at 6). This physician was the plaintiff's only expert testifying about the nursing standard of care. When his testimony was disallowed, therefore, the plaintiff had no evidence to offer regarding the nursing standard of care, and the judge directed the verdict in favor of the hospital.

The plaintiff appealed. One of the questions on the appeal to the Illinois Supreme Court was whether the trial court judge had made a legal mistake when he declared the physician not competent to testify as to the nursing standard of care and disallowed the physician's testimony. To answer this question, the Illinois Supreme Court first reviewed some of their previous decisions about who can testify as an expert. In Purtill v Hess (111 Ill2d 229, 489 NE2d 867 [1986]), the court had identified requirements needed to demonstrate an expert physician's competency to testify.

1. The physician must be a licensed member of the school of medicine about which he proposes to testify.

2. The expert witness must show that he is familiar with the methods, procedures, and treatments ordinarily observed by other physicians in a similar community.

Even after these requirements have been met, the trial court judge still has discretion as to whether the physician is qualified to state an opinion about the area of care in question.

The court then turned to what was meant by a "school of medicine" and noted that the Illinois statutes provided for separate regulation of medicine, surgery, physical therapy, nursing, pharmacy, dental surgery, podiatry, optometry, and other disciplines. The court accepted this as a clear statement by the legislature to recognize various schools of medicine--nursing among them. In other words, a physician would need to be licensed as a nurse and be familiar with the general area of prevention of patient falls to be allowed to testify about the nursing standard of care in this case.

The plaintiff then argued that his internist expert's lack of a nursing license should only influence how much weight the jury should give the testimony, not preclude him from testifying altogether. In its amicus brief, the Illinois Trial Lawyers Association also had urged the Court to allow physicians to testify about nursing standards. "There is nothing which a nurse can do which a doctor cannot do." (Sullivan at 13).

The Illinois Supreme Court rejected this proposition on the grounds that it "presumes a universal standard of treatment among physicians and nurses," and science and medicine have not achieved a universal standard of treatment of disease or injury (Id at 13). Instead, the Court quoted approvingly from the amicus brief of The American Association of Nurse Attorneys that

   A physician, who is not a
   nurse, is no more qualified
   to offer expert opinion
   testimony as to the standard
   of care for nurses
   than a nurse would be to
   offer an opinion as to the
   physician standard of
   care.... Certainly nurses
   are not permitted to offer
   expert testimony against a
   surgeon based on their
   observances of physicians
   or their familiarity with
   the procedures involved.
   (Id at 13)

By holding that physicians may not testify about nursing standards of care, this Illinois court gave judicial recognition to the fact that nursing is not a subcategory of medicine and has its own unique body of knowledge that only other nurses can be recognized as knowing.

GARLEY V COLUMBIA LA GRANGE MEMORIAL HOSPITAL

Later in 2004, an Illinois appellate court followed the Illinois Supreme Court's ruling that physicians may not testify about nursing standards (Garley v Columbia La Grange Memorial Hospital, Ill App LEXIS 817 [2004]). This appellate court re-emphasized that a physician cannot testify about nursing standards of care without being licensed as a nurse, even if he or she is aware of nursing practices. This court qualified in concurring opinions, however, that physicians can testify about what nurses should be expected to communicate to physicians about the patient's stares--because this is within physicians' expertise.

In Garley, the patient died from a pulmonary embolism three days after undergoing unnamed abdominal surgeries performed with the patient in the lithotomy position. Postoperatively, the patient did not ambulate until midday the day after surgery. She collapsed and died while ambulating the following evening. Although the pathologist noted the patient's left thigh and calf were larger than her right, the nurses who cared for her postoperatively testified that she did not exhibit any signs consistent with deep vein thrombosis or complain about pain in her legs. A patient care technician testified that the patient had complained of leg pain while ambulating, and that the technician relayed these complaints to a nurse. The patient's husband also testified that the patient had complained about pain in her legs.

Three experts testified at trial, none of them nurses. Two were obstetricians/gynecologists, and both testified that the nurses failed to ambulate the patient in a timely manner and failed to follow up on the patient's complaints of pain in her legs. The third, a general surgeon, also testified that the perioperative nurse failed to provide the applicable standard of care because she did not suggest to the surgeon that he use antiembolism devices during surgery. On cross examination, the surgeon stated that the nurse could defer to the surgeon as to how the patient should be positioned.

The jury returned a verdict against the hospital and the surgeon. The hospital appealed claiming the plaintiff's experts should not have been allowed to testify about nursing standards. The appellate court reviewed the Sullivan case as it applied to the Garley case and concluded that although the plaintiff's experts were well qualified and all would have satisfied the requirement that they were familiar with the methods, procedures, and treatments ordinarily used by nurses (ie, the second requirement identified in Purtill), none were licensed nurses (ie, they did not meet the first Purtill requirement). The court noted that the rule that health care expert witnesses must be licensed in the discipline about which they testify may be a rigid and formal rule, but because the rule was declared by the Illinois Supreme Court, only that court can overrule it.

JUDICIAL RECOGNITION

Although nurses may not like having nursing classified as a "school of medicine," this wording was required by the court's reasoning about the Illinois licensure statutes--that nursing is separate and distinct from medicine or surgery. The most important lesson from this case remains that physicians may not testify about nursing standards of care in at least one large state. This means nurses finally have achieved judicial recognition as being in a different profession than physicians, and nursing no longer can be considered a subcategory of medicine.

NOTE

(1.) E K Murphy, "The professional status of nursing: A view from the courts," Nursing Outlook 35 (January/February 1987) 12-15.

ELLEN K. MURPHY

RN, JD, FAAN

PROFESSOR EMERITA

UNIVERSITY OF WISCONSIN, MILWAUKEE

SCHOOL OF NURSING

MILWAUKEE

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