What happens when a nurse is ordered to do something illegal or unethical? What should a nurse do when ordered to falsify a patient's record? Is her behavior justified because she is following orders from a superior?

These important and troubling questions were raised but left unanswered by a recent Connecticut malpractice case. The case has received much attention because the verdict awarded the plaintiff— $3.6 million — is the largest in the history of the state. The case should interest nurses, not because of the record-making verdict, but because of ethical problems raised by the behavior of the attending staff.

This case concerns a new strand to an old yarn, the eternal triangle. It is new in that in addition to the usual cast, le mari, la femme, et l'amant (the husband, the wife, and the lover), new characters, the husband's “psychiatric team,” have been joined as parties. In fact, the “team” has been sued for the injuries inflicted on l'amant by le mari.

This is the first paragraph of a recent opinion by the Court of Special Appeals of Maryland entitled Shaw v. Glickman. The case is noteworthy not because of its racy facts, but because it stimulates further discussion of an important issue — the duty of a psychotherapist to reveal confidential information about a patient to protect the public or a specific individual.

As a society, we look to the law and the courts to vindicate and protect human rights. When the courts fail, the tragedy falls not only on the victim but also on all of us; human rights must be universal or we cannot be certain of them for ourselves. A recent California case illustrates that courts too sometimes fail to vindicate the rights of the weak and helpless.* While not specifically dealing with nursing, the case is so bizarre, and has received such publicity, that all nurses should be aware of its implications.

Talking about one's colleagues is a common practice in all employment settings. In the health care setting, one popular topic of conversation is evaluating and comparing the professional competencies of the various personnel.

When a nurse is aware that a colleague has made an error in judgment, or has failed to follow proper procedure, or has harmed a patient in some way, the nurse often chooses to share this information informally with other colleagues, rather than to report it through official channels. The rationale for this approach is generally that informal talking will do no one harm, while reporting through official channels may bring destructive disciplinary action upon the colleague, result in a lawsuit for defamation against the reporting nurse, or both. The problems with this rationale are illustrated by a recent New York court case.

The task that has perhaps most preoccupied professional nursing is that of defining itself. Over the years nursing has developed in such a way that currently there is a vast disparate group of individuals, each of whom may properly be called “nurse” — ranging from the licensed practical nurse to the nurse who holds a doctoral degree, with at least four levels of academic preparation between. It is evident that this situation poses problems, not only for nursing but also, and more importantly, for health care consumers who are unable to establish realistic expectations as to the knowledge and skills of “nurses.”

The formal role that nurses play in an institution's policy-making varies widely depending upon the institution. But regardless of their formal role, and whether they realize it or not, nurses are influencing policy-making every day by carrying out their nursing responsibilities. A nurse's influence may be positive or negative, depending upon her awareness.

Hospitals, like other large institutions, have many policies (both written and unwritten) designed to facilitate the smooth running of “business.” Since the major part of hospital business is caring for patients, most hospital policies have at least some effect upon its patients. For the purpose of discussing the nurse's role in policy-making, hospital policies which have an impact upon patient care may be divided into four categories: 1) patient care policies; 2) administrative policies; 3) business policies; and 4) “rules.”

Novella Trageser was hired by Libbie Rehabilitation Center in 1971, and in 1975 Libbie promoted her to Director of Nurses. She performed her duties capably, despite the fact that she had retinitis pigmentosa. During an inspection in 1976, a state certification officer from the Department of Health informally indicated disapproval of her employment because of her handicap. The home administrator relayed these comments to the board of directors, which resolved to dismiss her. Upon learning of this decision, Novella Trageser resigned and brought suit against the nursing home, partially on the basis of section 504 of the Rehabilitation Act.