1. Brooke, Penny Simpson APRN, MS, JD

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Bound by contract

I'm an OR nurse working at my first job. Because of my religious beliefs, I won't participate in surgery that involves an elective abortion if the mother's life isn't in danger. Could refusing to help with such procedures constitute a breach of contract that would nullify my employment agreement?-B.L., VA.


An employer usually hires a nurse with the expectation that he'll perform all the nursing duties needed to provide safe care to his patients. Unless the nurse and employer have specifically agreed that the nurse needn't take part in certain procedures, the nurse must fulfill his duties or risk being fired on grounds of insubordination.


Most staff nurses don't have formal written contracts with employers, but they should know what's expected of them in a new job and which actions could result in termination. The facility's employee handbook probably provides the most details about the employee-employer agreement, so review it before you accept a position. If you can't comply with certain terms of employment because of your beliefs, try to negotiate specific agreeable terms with the employer. If you succeed, get the negotiated conditions in writing for future reference and protection; new administrators at the facility could try to force duties on you that you've been excluded from performing.


In general, if you don't follow the hospital's policies and procedures, you can be fired and the employment agreement nullified.


What happens during a code

Keep it to yourself

In the cardiac care unit where I work, we have to document whether our patients want us to resuscitate them if necessary. What bothers me is that when patients or their families are asked to make this decision, they rarely understand what's involved in a code. Would I be treading on thin legal ice if I gave my patients and their families more details?-S.A., OHIO


Yes, for several reasons. First, federal law requires hospitals to ask patients at admission if they have a living will or advance directive. If a patient has one of these documents and his wishes include resuscitation efforts, his caregivers and family must respect his legal right to make that decision and not attempt to interfere with it. The patient's right to make medical decisions for himself is set aside only if he's been declared legally incompetent and another person given power of attorney, or in an emergency where a family member must act as a surrogate decision maker.


Second, your role in the process of getting informed consent from a patient is primarily limited to witnessing his signature. It doesn't include giving the patient or his family specific details about a procedure. It's the practitioner's job to describe the significant risks and benefits of treatment options. Describing every detail of a code could frighten patients and families out of requesting resuscitation efforts. It might also put you in conflict with the patient's practitioner and hospital administration.

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Liability for clinical instructor

Added legal risks?

I'm considering applying for a position as clinical instructor in a nursing program, but I'm concerned about the legal implications. What risks are involved, and should I change my malpractice insurance to cover them?-H.T., DEL.


Whenever you change your role or add new responsibilities such as becoming a clinical instructor, notify your personal professional liability insurance company in writing. Ask that they send a written response acknowledging the change so you're sure of coverage in your new role.


When you purchase malpractice insurance, you must honestly disclose the type of nursing you practice so the insurance company can evaluate the risk they're agreeing to cover. Without updated information, your insurer could disallow a claim involving harm to a patient while you're acting as a clinical instructor.


When you're responsible for supervising students, make sure you understand the expectations of both the nursing school and the clinical facilities where your students will be placed. Find out also what liability coverage is already in place for students' actions. The legal standard of care for what a reasonably prudent clinical instructor would do under the circumstances is helpful to determine if you'd be liable for harm caused by one of your students.


Forearmed with this knowledge, you needn't let the possibility of liability limit your career options if you have the education and experience to supervise and model safe nursing practice. Good luck.


Role boundaries

Who's calling the shots?

An LPN who works part-time in our unit is enrolled in a baccalaureate nursing program. On one of his student clinical days, he encountered a patient he normally cares for as an LPN. When she complained of pain, he checked her medication administration record (MAR) and saw that she could have a dose of her p.r.n. opioid analgesic. He prepared, administered, and documented the prescribed dose and signed off as an LPN. He didn't tell his instructor. A nurse who knew that he wasn't working as an LPN that day noticed the irregularity in the patient's medical record. Could this person be in legal hot water for signing off as "LPN"?-r.p., ariz.


Whether this person was acting as a student or an LPN, he took quite a risk-both with the patient's safety and his own career. He was working in his role as an RN learner, not an assigned caregiver, when he administered the opioid to the patient. As a student, he wouldn't have been given permission to proceed; as an LPN, he shouldn't have provided care to a patient when he wasn't on duty.


What if the patient' assigned nurse had already administered the medication but hadn't yet documented it in the MAR? The patient would have received an overdose. What he should have done was to report his assessment to the patient's assigned nurse.


Your colleague's nurse-manager and his clinical instructor should investigate what happened and get his side of the story. They may then be able to use this situation as an educational opportunity. However, because he accessed opioids without permission and showed poor judgment, he's at risk for losing his job.