North Carolina Registered Nurses are Now Subject to Malpractice Liability when Following the Orders of a Supervising Physician

In August of 2022, the North Carolina Supreme Court increased the risk of malpractice liability for registered nurses practicing in the state by overruling a prior decision that had shielded North Carolina nurses from certain malpractice liabilities for the preceding 90 years. The decision, styled as Connette v. Charlotte-Mecklenburg Hospital Authority, means that registered nurses in North Carolina can be held liable for medical malpractice even when acting on the direction of a supervising physician.

The Court in Connette emphasized the growing autonomy exercised by registered nurses in recent years, especially registered nurses additionally certified as advanced practice registered nurses or “APRNs,” who have additional practice privileges within their respective specialties. While legislation intended to increase nursing autonomy and to clarify the relative authority as between nurses and their supervising physicians has been introduced before the North Carolina House and Senate, such legislation has yet to be effected. Until the North Carolina legislature, Medical Board, or Board of Nursing provides additional guidance, the Connette decision will require registered nurses and APRNs to engage in a delicate balance of independently assessing the viability of treatment proposed by supervising physicians, without exceeding their respective scopes of authority.

As noted above, pursuant to the 1932 North Carolina Supreme Court decision Byrd v. Marion General Hospital, North Carolina nurses have historically been exempt from medical malpractice liability when acting under the direction of a medical doctor, so long as they “diligently execute the orders of the physician or surgeon in charge of the patient, unless . . . such order was so obviously negligent as to lead any reasonable person to anticipate that substantial injury would result.” While North Carolina’s medical malpractice statute does contemplate medical malpractice actions against registered nurses for professional services rendered in the performance of “medicine,” “nursing,” providing “assistance to physician,” and other types of health care, the common law protection for nurses acting under the supervision and direction of a physician has been consistently applied into the twenty-fist century. Thus, while nurses could be held liable for failing to follow a supervising physician’s directives or for following directives that would obviously cause a patient harm, they were generally shielded from malpractice flowing from a negligent diagnosis or the negligent selection of improper treatment of a patient.

In Connette, however, the Supreme Court of North Carolina overturned these historical protections and held that “even in circumstances where a registered nurse is discharging duties and responsibilities under the supervision of a physician, a nurse may be held liable for negligence and for medical malpractice in the event that the registered nurse is found to have breached the applicable professional standard of care.” The decision was not unanimous. In a dissent joined by Chief Justice Paul Newby, Justice Tamara Barringer argued that the Court usurped legislative authority, considering that “the legislature . . . has adopted and codified the holdings in Byrd in its statutes [r]ather than supplanting them.”

In the wake of the 2022 decision, North Carolina’s nurses are left without clear guidance on the appropriate balance of authority when working collaboratively with their supervision physicians. On one hand, nurses face clear malpractice liability associated with failure to follow the orders of a supervising physician. However, in the wake of Connette, both registered nurses and APRNs may be required to more carefully scrutinize the treatment selected by the physician, all while remaining within their respective scope of nursing practice.