What is the responsibility of a hospital to protect the general public from an employee who may cause harm? Until recently, the answer to this question was simply “none“; hospitals were not seen as having any direct responsibility for the actions of employees. But this has changed, and the current trend is to hold a hospital directly responsible for the level of care received by its patients — the hospital must provide an ongoing system to monitor performance of employees as well as staff physicians.

But what about acts of employees outside the hospital? Does a hospital have any obligation to anticipate when one of its employees poses a threat not on the job? This was the question addressed in a recent case before a California appeals court.

It is easier to identify an ethical dilemma than to solve it; this is the nature of the beast. In the process of deciding what to do, nurses are often pulled by conflicting demands from employers, patients, physicians, and other nurses: the feeling is that no resolution can be found which will satisfy everyone. A most difficult situation arises when the nurse feels an obligation to act in the best interests of patient care, but knows that to do so may be detrimental to her employer. When this happens, the nurse may fear that action to protect the patient will result in her being fired or some other form of retaliation by the employer. This fear is not entirely unfounded — employers do sometimes fire nurses who speak out against institutional policies. But a recent federal court case demonstrates that a hospital cannot summarily fire a nurse who acts responsibly in seeking to bring about institutional change.

The lesson of this column is: In an emergency, treat first and ask legal questions later. This is both good medicine and good law.

There is no universally recognized definition of an emergency, and the law will generally accept the determination of health care professionals, if consistent with accepted practice, in defining an emergency condition or situation. The most common definition is that an emergency is any injury or acute medical condition liable to cause death, disability, or serious illness if not immediately attended to.

Obvious examples of emergency conditions that require the immediate attention of a physician or properly trained health professional to prevent loss of life include:

• Massive hemorrhage from major vessels

• Cardiac arrest

• Cessation or acute embarrassment of respiration

• Profound shock from any cause

• Rapidly acting poison

• Anaphylactic reactions

• Acute epidural hemorrhage

• Acute overwhelming bacteremia and

• toxemia

• Severe head injuries

• Penetrating wound of the pleura or pericardium

• Rupture of an abdominal viscus

• Acute psychotic states.

Nursing must develop techniques for handling controversy. As nursing becomes a more visible and diverse part of the health care system, it must increasingly respond to commentary and criticism — from other providers, from consumers, and from within. Nursing can respond productively to this review, thereby enhancing professional growth and contributing to a positive professional image.

An examination of nursing attitudes toward controversy should focus on the preparation — both formal and informal — provided for student nurses in this area. The ability to deal productively with controversy depends upon skills and attitudes; nursing programs must emphasize both of these to truly prepare students who will represent nursing favorably. I have identified four major areas in which nursing can strive to achieve this goal.

Should nurses carry their own malpractice insurance? This is a commonly asked question, to which no simple response can be given. The answer will be different for each individual nurse, and will depend upon a variety of factors; individual personal values will determine which factors are most important. Thus, while it is impossible to offer a definitive answer which is correct for all nurses, it is possible to provide a framework to aid in the development of individual answers. For purpose of discussion this column will examine the nursing malpractice insurance question from three perspectives — legal, ethical, and professional — though in reality, of course, the three overlap.

The legal issues raised by the malpractice insurance question are the most straightforward and therefore the easiest to deal with. The first question is: do nurses need malpractice insurance at all? Nurses are now viewed (legally and otherwise) as professionals accountable for their own actions.