Guides · Medical malpractice

Nurses as Expert Witnesses: Standard of Care and Causation

Claims against hospitals and nursing homes are often claims about nursing: missed assessments, unreported changes in condition, pressure ulcers, falls. The natural expert is a nurse, and on the nursing standard of care courts generally agree. The disputes are at the edges. May a nurse say what a physician should have done? May a nurse say that the nursing breach caused the injury? And when a physician has already covered the nurses, does a nursing expert add anything? This guide covers each question with recent decisions, and ends with a checklist for building or attacking nursing testimony.

Guide 13 of 13 · November 10, 2026 · 6 min read
On this page
  1. Nursing standard
  2. The physician line
  3. Causation
  4. Ulcers vs. death
  5. Cumulative testimony
  6. What to prepare

The nursing standard of care: generally accepted

Courts routinely accept registered nurses, and especially nurses with clinical and teaching experience in the relevant setting, as experts on the standard of care for nurses: assessment and reassessment, monitoring, documentation, care planning, and escalation to a physician. Statutes that require a peer of the defendant usually treat a nurse as the peer of a nurse. Maryland's malpractice statute, for example, requires the certifying expert to have recent clinical experience in the defendant's specialty or a related field of health care, and the Supreme Court of Maryland held in Canton Harbor Healthcare Center v. Robinson (Md. 2025) that a registered nurse meets that peer requirement to the extent the nurse attests to breaches of nursing standards.

The physician line

The same courts draw a firm line at physician care. A nurse is generally not qualified to define a physician's standard of care or to say a physician breached it. Canton Harbor held that a nurse does not meet Maryland's peer requirement to the extent the nurse attests to the standard of care applicable to a physician. Washington's Supreme Court noted in Frausto v. Yakima HMA (Wash. 2017) that it has long held that only physicians may testify to another physician's standard of care, and did not revisit that rule.

The line matters most when the claim mixes nursing and medical care. In Bean v. St. Francis Hospital (Okla. 2026), a patient sued over a contrast infiltration from an IV placed for a CT scan. Her only expert was a registered nurse. The Oklahoma Supreme Court held that the nurse was not qualified to testify to the hospital physician's standard of care and did not establish causation between any negligence of the hospital's employees and the injury, vacated the Court of Civil Appeals' opinion, and affirmed summary judgment for the hospital.

Causation: the main split

Whether a nurse may testify that a nursing breach caused the injury is where jurisdictions differ. The traditional view is that medical causation requires a physician. A growing number of courts reject a categorical bar and ask instead whether the particular nurse has the knowledge to answer the particular causal question.

Frausto is the leading example. A quadriplegic patient developed pressure ulcers in a hospital, and his expert was an advanced registered nurse practitioner with more than thirty years of practice and teaching. The trial court accepted her on the nursing standard of care but held that the law barred her from testifying to proximate cause. The Washington Supreme Court reversed. It held that nurse practitioners are not disqualified as a matter of law from testifying to causation, and that the trial court must decide under the ordinary expert rule whether the witness is qualified. Because Washington lets nurse practitioners independently diagnose and treat within their certification, the court reasoned that the ability to diagnose a condition is strong evidence of expertise to discuss its cause. The court also observed that a majority of jurisdictions permit nurse testimony on causation.

Canton Harbor reached a similar result for registered nurses on a narrower ground. A resident developed pressure ulcers at a skilled nursing facility, and the claim was certified by a registered nurse who attested that breaches of nursing standards caused them. The trial court dismissed. The Appellate Court reversed, and the Supreme Court of Maryland affirmed, with a plurality holding that a nurse may attest to proximate cause of a previously diagnosed pressure ulcer. The nurse does not make the diagnosis; she accepts the diagnosis made by others and opines that departures from nursing standards caused it, which the plurality held is within the bounds of nursing practice. Three justices would have reversed in part.

Georgia takes a similar functional approach. In Evans v. Medical Center of Central Georgia (Ga. Ct. App. 2021), a cardiac patient was discharged and died, and the plaintiff alleged that a nurse failed to identify and communicate his signs and symptoms to the physician. The defendants argued that the plaintiff's nurse expert could not testify to causation because that issue belongs to a medical doctor. The Court of Appeals disagreed: the question was the identification of signs and symptoms, not a medical diagnosis, and whether the failure to communicate them led to a premature discharge. It reversed summary judgment.

Pressure ulcers versus cause of death

The cases that allow nurse causation testimony cluster around problems that are primarily nursing problems, above all pressure ulcers, where prevention, assessment and treatment are core nursing work. They are much less receptive when the causal question is a complex medical one.

Funk v. Pinnacle Health Facilities (D. Kan. 2018) shows the boundary. A nursing home resident fell and fractured her hip, underwent surgery, fell again at another facility two weeks later, and died the following month. The plaintiffs' experts were a registered nurse and a licensed practical nurse. The court held that neither could testify to the cause of death. It read Frausto as rejecting a categorical bar, not as approving nurse testimony on medical causation generally, and noted that the decisions permitting nurse causation testimony overwhelmingly involved bedsores. Preventing falls is a nursing problem, the court said, but whether the fall caused the death of an elderly patient with many conditions, after surgery, is a medical question. The claim survived only because the coroner's death certificate supplied evidence of causation.

The practical lesson is to frame the nurse's causal opinion as narrowly as the facts allow, tied to a diagnosis already made, and to bring a physician for any causal step that requires one.

Cumulative testimony

A nurse expert can also be excluded for adding nothing. Trial courts may limit the number of experts on a topic, and a physician who testifies about the nurses may make the nursing expert duplicative. In Smith v. Clark (W. Va. 2019), the trial court had limited each side to one standard of care expert per specialty, one for the physician and one for the nurses. At trial the plaintiff's physician expert testified that the labor and delivery nurses breached the standard of care, and the court struck the plaintiff's nursing expert as duplicative. The Supreme Court of Appeals affirmed.

The choice is strategic. A physician who criticizes the nurses may be the more powerful witness on causation, but a nurse is usually the more credible witness on what nurses are trained and expected to do. If both are needed, keep the physician off the nursing standard so the nurse's testimony is not cumulative.

What to prepare

  • Separate the nursing claims from the physician claims, and assign each to the right expert.
  • Choose a nurse with clinical and teaching experience in the same setting: medical-surgical floor, labor and delivery, long-term care.
  • For causation, check whether your jurisdiction bars nurses categorically or asks whether the particular nurse is qualified.
  • Tie any nursing causation opinion to a diagnosis already made by a physician, and keep it to nursing problems such as pressure ulcers and missed escalation.
  • Bring a physician for complex medical causation, such as cause of death in a patient with several conditions.
  • Do not let the physician expert testify to the nursing standard if a nursing expert will also testify.
  • When defending, attack any nurse opinion on physician care, and any causal opinion that requires a medical diagnosis.

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Sources

This guide is general information, not legal advice.

How each court of appeals applies amended Rule 702: see the Rule 702 tracker.

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Experts in this guide's practice

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The series

13Medical malpractice · November 10, 2026Nurses as Expert Witnesses: Standard of Care and Causation12Medical malpractice · November 3, 2026Who May Testify to the Standard of Care: Specialty Rules in Malpractice Cases11Commercial · October 27, 2026Lost-Profits Experts: Reasonable Certainty and Rule 70210Mass tort · October 20, 2026General Causation in Mass Torts: Bradford Hill Under Rule 70209Securities · October 19, 2026Section 11 Damages and Negative Causation08Antitrust · October 19, 2026Overcharge Regressions in Price-Fixing Cases07Antitrust · October 19, 2026How Often Courts Exclude Antitrust Economists, and Why06Securities · October 13, 2026Loss Causation, Damages and the Inflation Ribbon05Securities · October 6, 2026Market Efficiency at Class Certification: Cammer and Krogman04Any expert · September 29, 2026Amended Rule 702 After Nearly Three Years: What Courts Exclude03Antitrust · September 22, 2026Common Impact and Pass-Through at Class Certification02Securities · September 15, 2026Price Impact at Class Certification After Goldman01Securities · September 8, 2026Daubert Challenges to Event Studies in Securities Cases

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