Sugiyama et al. BMC Nursing(2020) 19:62
https://doi.org/10.1186/s12912-020-00458-2

RESEARCH ARTICLE

Open Access

Japanese nurse practitioners’ legal liability
ambiguity regarding their medical practice:a qualitative study
Shoko Sugiyama*, Kyoko Asakura and Nozomu Takada

Abstract
Background: Nurse practitioners’ role is always expanding. The Japanese Nurse Practitioner (JNP) system wasinitiated in 2015 to shift some aspects of doctors’ work to various other healthcare professionals, including nurses.
JNPs’ fulfillment of their roles was shown to have a certain degree of efficacy and provide positive outcomes forpatients (e.g., shortening hospitalization period). Nurse practitioners are considered legally liable for their medical
practices because they are performed on doctors’ behalf; however, in real life, there is ambiguity regarding suchpractice. It is necessary to clarify nurse practitioners’ legal liability in order to ensure the safety of their medical
practice and protect them in medical procedures performed on physicians’ behalf. This study aimed to clarify how
JNPs understand their own legal liability in medical practice.
Methods: A qualitative, inductive research design was adopted to record participants’ opinions. The survey was
conducted from October 2017 to February 2018. Participants were nurses working as JNPs at general hospitals ineastern Japan. We recruited participants via snowball sampling.
Results: With regard to JNPs’ legal liability in their medical practice, three themes understanding were observed:“determining whether the JNP has the ability to perform the assigned medical procedure,” “exercising caution
when performing medical procedures on a doctor’s behalf” and “an urge to follow up with appropriate medical
practice until the end of care.”Conclusions: We demonstrated that JNPs recognized their own legal liability in medical practice. They had toprotect themselves because their legal position was ambiguous. Furthermore, JNPs accepted that diagnosis anddrug prescription could be performed on behalf of doctors if trusting relationships had been previously established.
Keywords: Japanese nurse practitioner, Medical practice, Nurse practitioner, Legal liability, Qualitative study

Background
Nurse practitioners’ (NPs) role is always expanding. The
scope of the medical practice performed by NPs varies
somewhat from country to country and state to state,
and NPs are able to perform certain levels of diagnosis
and treatment autonomously [1]. Moreover, they compensate for doctor shortage and provide medical care in* Correspondence: s.sugiyama@med.tohoku.ac.jp
Tohoku University, Graduate School of Medicine, 2-1, Seiryo-machi, Aoba-ku,
Sendai, Miyagi 980-8575, Japan

areas where such shortage exists [2]. For example,
although there are some differences between countries,
NPs in the United States [3], the United Kingdom [4],Canada [5], and Australia [6] are permitted to perform
diagnoses, order tests, and prescribe medications. The
Japanese Nurse Practitioner (JNP) system was initiatedin 2015 to shift some aspects of doctors’ work to various
other healthcare professionals, including nurses [7].
Depending on how JNPs fulfill the requirements of arole, effectiveness measurements, such as shortening the© The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License,
which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give
appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate ifchanges were made. The images or other third party material in this article are included in the article's Creative Commonslicence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commonslicence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain
permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to thedata made available in this article, unless otherwise stated in a credit line to the data.

Sugiyama et al. BMC Nursing(2020) 19:62

hospitalization period for patients and early response to
emergencies [8, 9], have been observed for patients andinstitutional users: For example, in cases where NPs care
for adult patients with chronic renal failure, the effective
management of blood pressure, cholesterol, and blood
sugar levels was found to be outstanding compared togeneral care [10]. Additionally, in nursing homes, NP
intervention was shown to significantly reduce the numberof times emergency transportation was used and to shorten
the duration of hospitalization for patients [11]. Moreover,when the actions of NPs and physicians were compared inemergency rooms, there was no significant difference foundin the number of tests ordered in triage, and the small difference observed did not affect patients’ overall time spentin emergency room beds [12]. NPs possess a high degree ofknowledge [5], are able to make quick diagnoses and judgments [6], can respond to changes in patients’ conditions[7, 10, 11], and provide patients with necessary medical careon behalf of doctors [2–7, 10, 11].
Moreover, NPs are considered legally liable for their
medical practices because they are performed on doctors’ behalf; nonetheless, in reality, there is some ambiguity regarding the exact situations in which NPs can beheld liable for their medical practice. For example, incases in which NPs and physicians work together, although NPs’ activities are evaluated by the doctor, there
is some overlap in their scope of practice (i.e., NPs canprescribe drugs and perform some, but not all, advanced
medical practices) [13], making the issue of legal liability
vague [14]. Additionally, NPs are legally unable to independently perform advanced medical procedures [15].
Although NPs are an integral part of medical teams inemergency departments, they must have sufficient practical ability to ensure the medical practice safety andavoid litigation [16]. Nonetheless, given the fact thatNPs hold a large amount of responsibility regarding theirpractice and that the number of patients to whom an
NP responds increases in a daily basis, the number of
medical malpractice insurance claims has also been increasing in countries such as the United States, wheresuch litigation is particularly commonplace [17]. Hence,
it is necessary to clarify NPs’ legal liability so as to ensure the safety of medical procedures and protect NPs
regarding their medical practices performed on physicians’ behalf.
In Japan, discussions on the JNP system are ongoing.
Currently, JNP refers to a nurse who has undergone specific training in a master’s program, has a master’s degree, and is certified by Japanese Organization Nurse
Practitioner Faculties. JNPs may be more responsible for
performing medical procedures than a non-trained
nurse. Although the Public Health Nurses, Midwives,
and Nurses Law was partially revised due to the enforcement of the JNP system in 2015, doctor instruction

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remained necessary when JNPs provided medical treatment even after the law’s revision. Despite their specialized training, JNPs cannot make judgments regarding
the practice of medical treatments on their own, and,like general nurses, assist in medical action under the
direction of a doctor. It can be construed that JNPs may
be more liable than a general nurse if a medical accident
results from their medical assistance. According to the
Public Health Nurses, Midwives, and Nurses Law, whena medical accident occurs due to an action performed by
JNP under the direction of a doctor, both the doctor and
JNP can be interpreted as legally responsible. This increased liability may result from JNPs having specifictraining, a master’s degree, and more advanced knowledge and skills. As a result, under the current JNP system, JNPs cannot assess a patient’s condition and decideon the necessary medical action, but face a situation
where legal liability is found for medical accidents performed under a doctor’s instruction.
At this stage, JNPs’ legal responsibility regarding medical actions is ambiguous. JNPs are not self-employed.
Because they are hired by a hospital, their practices, andthus the scope of their liability, vary according to thehospital’s regulations. To date, there have been no cases
where JNPs have been held liable in Japan. However, if aregular nurse is involved in a medical accident, thenurse, the doctor who issued the instructions, and thehospital that employs the nurse are legally liable. Similarly, if a problem arises concerning the actions taken by
a JNP, the legal responsibility may be imposed on the
JNP, the doctor who issued the instructions, and the employer’s hospital [18]. Thus, this study aimed to determine how JNPs understand their own legal liability inmedical practice. The results provide suggestions regarding patient safety and NPs’ legal protection. Additionally,knowledge accumulation on the topic can help expand
the role of JNPs in the medical setting.

Methods
Research design

Nursing practice is a fluid phenomenon that is influenced
by various contexts, such as the human influences ofnurses, patients, or medical professionals; environmental
issues; and the situations surrounding the practice itself.
However, it is difficult to control so many contexts in research. Therefore, we used a qualitative and inductive research design that could comprehensively capture thephenomena of JNPs’ thought processes and the surrounding context. This design allows for better understanding
the wholeness of a phenomenon and for discovering its inherent depth, richness, and complexity via its meaning[19]. The study was also conducted as a preliminary survey to examine nurses’ responsibilities. This study was
conducted using researchers and a PhD candidate with

Sugiyama et al. BMC Nursing(2020) 19:62

experience in qualitative data collection and analysis.
These researchers were continuously involved in the research planning, data collection, data analysis, and manuscript writing phases of the study.

Page 3 of 6

research and nurses with experience in nursing research.
This was done to ensure the credibility and validity ofthe study content and results.

Results
Setting and participants

JNPs’ understanding of legal liability in medical practiceThe survey was conducted from October 2017 to February
2018. Participants were three nurses working as JNPs at
general hospitals in the eastern region of Japan. Researchers explained the purpose of the study to six JNPs
and invited them to participate in the study, and threeconsented to do so. These three JNPs belonged to the cardiac surgery, respiratory medicine, and emergency departments. Each JNP had between 9 and 22 years ofexperience as nurses in addition to 2–5 years’ experience
as an NP. However, in certain hospitals, even if one has
obtained the JNP qualification, situations in which working as a JNP at one’s affiliated hospital is not permitted
could arise. The inclusion criterion for participation in the
study was being an active JNP employee for more than 2
years. We recruited participants via snowball sampling.

The results of the analysis of JNPs’ legal liability in their
medical practice revealed three themes: “determining
whether the JNP has the ability to perform the assigned
medical procedure,” “exercising caution when performing medical procedures on a doctor’s behalf,” and “anurge to follow up with appropriate medical practice until
the end of care.”“Determining whether the JNP has the ability to perform the assigned medical procedure”
With regard to the first theme of understanding, data
showed that even if a JNP was requested or permitted bya doctor to perform a medical procedure on that doctor’s behalf, the JNP was responsible for assessing thepatient’s condition, identifying procedure should be performed and how, and determining whether to performthe medical procedure. Depending on the type of medical procedure involved, even if there was no problem
with a JNP’s ability to perform the procedure, it was possible that the patient’s state could suddenly change to
one that would require a doctor because of procedure
implementation. Therefore, even if JNPs were allowed toperform a certain medical procedure by a doctor, theymight not do so if they judged it to be dangerous.

Data collection

Data were collected via participant observation and interviews. Researchers initially observed JNPs and took fieldnotes on how JNPs practice nursing. We did so because
nurses are not always aware of their legal liability during
their own practice and because it would be easier to reconstruct specific and factual scenarios during subsequentinterviews. The observed scenarios included handovers
between JNPs, confirmation of a doctor’s instruction, conferences with medical staff, and patient-related practices.
Observations were conducted for 2–3 days for each JNP.
Individual interviews were conducted once (or twice, if afollow-up was warranted) for each JNP and took place inrooms in which privacy could be maintained. Each interview lasted approximately 1 h. Based on the field notes, we
asked JNPs to think about their own legal liability, and weused certain examples of their medical practice acquired
through observation. Each interview was recorded withthe participant’s permission.
Data analysis

We comprehensively described JPNs’ legal liability withregard to certain medical procedures. The theme of theanalysis was “how JNPs understand their own legal liability in medical practice.” We minimized bias as muchas possible as we proceeded with our research. In particular, when analyzing data, it is possible that researcher
bias could arise in data interpretation; therefore, after
creating specific conclusions about the data, we analyzed
their appropriateness by constantly returning to the actual data. Further, to minimize such bias, we were supervised by researchers with experience in qualitative

In medical practice, it cannot be said that accidents
will definitely not occur. Specifically, when performing invasive procedures in place of the doctor, thedoctor says, “I leave everything to you, so you can doanything.” However, if any complications occur after
medical procedures, the doctor may say, “You were
the one who did this.” In that case, it becomes difficult, because I’m forced to accept legal liability.
When it comes to legal liability, I feel that I have to
be careful when dealing with it. (NP2)

I only choose to perform medical procedures that do
not entail complications, so I haven’t performed aperipheral insertion of a central catheter, I neverperform such difficult medical procedures. In otherwords, I restrict myself. There are 38 medical procedures I am qualified to perform, but I do not do allof them. I will not even do the exchanges requiredfor gastric fistulas. I try to simulate the procedure in
my head and do hands-on medical practice. Once I
become confident, I can carry out the medical procedure while being occasionally observed by a doctor.
I think that I cannot perform medical procedures

Sugiyama et al. BMC Nursing(2020) 19:62

that have a high risk, and I do not perform medical
procedures that I deem risky. (NP3)“Exercising caution when performing medical procedures on a doctor’s behalf”
For the second theme, the data showed that when
JNPs were tasked with performing medical procedures
on behalf of a doctor that were not among their specified 38 performable medical tasks, they experienced anxiety about whether or not they should be performing thetasks and felt pressure to not make mistakes while doing
so. By law, JNPs do not have the authority to directly
provide a diagnosis and/or prescription. However, when
doctors had JNPs act as their substitutes, the latter provided patients with diagnoses and prescriptions. Although these actions performed on behalf of a doctor
were ultimately confirmed by the doctor, who remained
responsible for determining the content of the orders,the JNPs were required to input their own ID numbers
to implement these medical procedures (i.e., diagnosis
and prescription). This requirement led to JNPs feelingpressured to not make mistakes, mainly due to the anxiety evoked by the possibility of being legally liable if
mistakes occurred.
For cases such as fractures, I write down the diagnoses. I have to write things like “there is a fracturehere” on behalf of a doctor, so I cannot afford to
make any mistakes. That is my number one [priority]. Because there cannot be any mistakes, I feel that
I have to write diagnoses down properly. I cannot
write down any misdiagnoses. (NP 3)

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signified by repeatedly confirming the progress of thepatients involved in their medical practices. Furthermore, in understanding the changes that resulted fromtheir direct actions on patients, JNPs were able to moreclearly comprehend their legal liability.
Basically, I see my patients the whole time until they
are discharged. Occasionally, I go to see patients
when they come in for outpatient care. I ask them“How are you doing? Are you taking care of yourself?” Sometimes the patients come to see me. I am
involved in [protecting] the lives of the patients, so I
am worried about them … I think that for the patients, hospitalization is a turning point in theirlives. It is a life-changing experience, so I wonder
how patients’ lives have changed and how they are
doing. (NP1)

I think that it is ideal to check and assess bed sores
and debridement every day, but I cannot follow up
on this, because I can only check and assess thoseconditions once a week. I have to leave it to the doctors or other nurses, but I hesitate leaving those tasks
to others … The patient’s condition may be alrightwhen I assess them, but infection, bleeding, or something else could set in later on. These things are realpossibilities, so I think I need to be somewhat cautious. If our hospital was not so far from the patients, we would be able to respond to them more
quickly. (NP2)

Discussion
Ambiguity of JNPs’ position in the legal system

I prescribe medicine on my own, so it is very scary. I
cannot prescribe medicines that I am unfamiliar
with, so, in such cases, I ask somebody—for example,
pharmacists or doctors who are familiar with the
medicine. When my doctor tells me to prescribe
medicine, I ask the doctor why this medicine is necessary … Because I am the one giving instructions
for the medicine; it is scary to prescribe it without
knowing the patient’s state or the effect of the drugs.
(NP 1)“An urge to follow up with appropriate medical practice until the end of care”
For the third theme of liability understanding, the data
showed that JNPs were concerned about patients’ progress after they had performed medical practices onthem, and they wanted to ensure that such patients were
followed up with until the end of their hospital stay, so
as to not leave anything unfinished. Although JNPs cannot directly treat their patients, their responsibility was

Our results indicated that JNPs carefully determined
whether they were able to perform certain medical procedures and assessed the difficulty of a medical practicewhen they were asked to perform tasks on a doctor’s behalf. Our results were identical to those of a previous
study showing that the law was a barrier to NPs’ independent practice [15]. JNPs practice medical proceduresin training; therefore, they are able to implement theprocedures if they intend to do so [20]. However, if complications occur owing to the performed medical procedures, additional medical intervention is required totreat the complications. The medical procedures thatNPs perform are carried out under a doctor’s directions.
However, any additional medical care was regarded asgoing beyond the range of actions that can be performedby the JNPs’ own judgments or by them under a physician’s direction. Moreover, JNPs reportedly considered
whether the medical procedures they performed caused
complications, and whether they needed to perform
further medical procedures to minimize patient’s risks.

Sugiyama et al. BMC Nursing(2020) 19:62

Based on our observations, we believe that JNPs’ follow
up of the medical procedures they have performed was an
expression of their perceived responsibility. In team-based
medical care, where cooperation exists between doctors
and pharmacists, it becomes difficult to clarify JNPs’ scopeof responsibility and roles when performing specific procedures [21]. Even in Japan, the existence of JNPs in medical
practice is not widely implemented, and it has been shownthat ascertaining JNPs’ role is a difficult task [22]. In thecurrent study, the range of medical procedures performed
by JNPs differed between facilities and medical departments. With respect to the unclear scope of JNPs’ role, thismay be owed to the fact that each facility or department
recognizes the scope of activities that this professionalgroup should perform in different ways; namely, there is inconsistency between these institutions. In situations where
JNPs’ role is unclear, it may be assumed that societal reaction to the failure of a medical procedure would differ
based on who performed the actions that led to the failure—a doctor or a JNP (despite the fact that, to date, there
have been no cases in which a JNP who caused a medical
accident was subject to a lawsuit). Given the fact that Japanese law recognizes and allows for physicians to perform
medical procedures, this also implies that they are liable forthe procedures they perform. Contrastingly, JNPs’ role is
not clearly recognized by Japanese law, despite this professional group’s desire for this legal liability to be more clearly
defined. Therefore, the issue surrounding responsibility for
medical procedures performed by JNPs under the instruction of physicians requires further consideration with respect to who should be held legally responsible for medical
accidents, suggesting the need to further explore individual
practitioners’ authority and scope of obligations.
Relationship between JNPs and physicians

Results showed that JNPs felt pressured when performing medical procedures on doctor’s behalf. Particularly,
JNPs felt pressured to diagnose and prescribe medication
to patients on physician’s behalf. It may be assumed that
JNPs accepted performing these activities on doctor’s behalf because they wished to fulfill the latter’s expectations, and the pressure to avoid misdiagnoses orincorrect prescriptions may have come from their intent
to not bother their superiors (doctors). Further, we believe that, in our sample, doctors requested for JNPs toperform such activities in consideration to their abilities
and because they are subordinates. Finally, we think that
although the roles of JNPs are somewhat ambiguouswith respect to diagnoses and prescriptions, they manage
to handle the pressure of being a substitute for doctors
by establishing trusting relationships with them.
When a doctor instructs a JNP to prescribe a drug thatis unknown to the JNP, the JNP typically checks the
drug information, such as its efficacy for the patient’s

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symptoms, side effects, and proper use, with a doctor or
pharmacist. A previous study has shown that comprehensive drug evaluations by NPs promote the effective
symptom management of patients and effective medical
economy regarding drug prescription tailored to patients’ needs [23]. Including such tasks within the educational and training curricula of JNPs, whereby they canmodify the dosage of drugs or change the drug to be administered according to the patient’s condition, may leadto enhanced treatment and nursing tailored to eachpatient’s condition.
Limitations of the study

The results of this study are based on interviews and observations of three JPNs working in hospitals; it was difficult to recruit research participants because in Japanesehospitals, JNPs often work under doctors’ supervision,and the doctors tend to not grant permission for participation. Moreover, JNPs have not had the opportunity todemonstrate their understanding of all legal responsibilities, as no lawsuits have yet been filed. However, thesefindings provide a better understanding of JNP’s roles
and actual working conditions and suggest that their
responsibilities need to be further clarified.

Conclusions
Through this study, we clarified that the JNPs in ourstudy recognize their own legal liability in medical practice; their legal responsibility regarding the implementation of medical procedures was based on three recurring
themes that appeared in the qualitative analyses we performed: 1) “determining whether the JNP has the ability
to perform the assigned medical procedure,” 2)“exercising caution when performing medical procedures on adoctor’s behalf,” and 3) “an urge to follow up with appropriate medical practice until the end of care”.
Our results showed that JNPs were in a situation inwhich they had to protect themselves because their legal
position was vague. Further, even if they performed legally ambiguous medical procedures, they still chose tofulfill their responsibility as JNPs and performed theseprocedures. We surmise that if JNPs’ legal liability scope
was more clearly defined or if JNPs’ roles were to be expanded, perhaps they would be able to fulfill their tasks
without feeling anxious as to whether or not they areoperating within the scope of their legal liability.
Abbreviations
JNP: Japanese nurse practitioner; NP: Nurse practitioner
Acknowledgements
We would like to thank the JNPs and the nursing departments of thehospitals selected for this study for their support during data collection. The
authors declare that they have no competing interests.

Sugiyama et al. BMC Nursing(2020) 19:62

Authors’ contributions
SS and KA contributed to designing the study; SS collected the data; SS, KA,
and NT analyzed the data; and SS, KA, and NT wrote the final report andmanuscript. All the authors read and approved the submitted version.
Funding
The authors disclosed receipt of the following financial support for the
research and authorship of this article: This work was supported in part ofGrants-in-Aid for Young Scientific for 2019–2021(no. K19K195260, Shoko Sugiyama) from the Japan Society for the Promotion of Science.
Availability of data and materials
Datasets generated and analyzed during the current study are not publicly
available but can be made available from the corresponding author upon
reasonable request.
Ethics approval and consent to participate
The study was approved by the ethics committee at Tohoku University
Graduate School of Medicine (Approved July 24, 2017). The study wasdescribed in detail, both in writing and verbally, to the nursing department
manager and participants at the facility at which the JNPs worked.
Thereafter, written informed consent was obtained from all participants.
When necessary, the study documents were submitted to the ethics
committee at the nurses’ facility, and their approval was obtained. We
assured participants of anonymity, freedom, and their right to suspend orwithdraw participation in the research at any time. We explained thebenefits and disadvantages of participation in the research, how we would
manage the collected data, and informed participants that the data would
be used only for research purposes.
Consent for publication
Not applicable.
Competing interests
The authors declare there is no competing interest.
Received: 14 August 2019 Accepted: 2 July 2020

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