Exam 5 Ch 23

Quasi-Intentional Torts

-Invasion of privacy -Defamation of Character

Consent

-Consent form -Informed Consent

Federal Statutory Issues in Nursing Practice

-Patient protection and Affordable Care Act (PPACA) -Americans with Disabilities Act (ADA) -Emergency Medical Treatment and Active Labor Act -Mental Health Parity Act -Uniform Anatomical Gift Act -Living wills -Durable power of Attorney -HIPPA -Advance Directives -Restraints

Civil and Common Law Issues in Nursing Practice

-Torts -Intentional Torts -Quasi-Intentional Torts -Unintentional Torts -

Criminal Law (felonies or misdemeanors)

-meant to prevent harm to society and to provide punishment for crimes. -categorized as a felony or misdemeanor

10. A patient has a fractured femur that is placed in skeletal traction with a fresh plaster cast applied. The patient experiences decreased sensation and a cold feeling in the toes of the affected leg. The nurse observes that the patient's toes have become pale and cold but forgets to document this because one of the nurse's other patients experienced cardiac arrest at the same time. Two days later the patient in skeletal traction has an elevated temperature, and he is prepared for surgery to amputate the leg below the knee. Which of the following statements regarding a breach of duty apply to this situation? (Select all that apply.) 1. Failure to document a change in assessment data 2. Failure to provide discharge instructions 3. Failure to follow the six rights of medication administration 4. Failure to use proper medical equipment ordered for patient monitoring 5. Failure to notify a health care provider about a change in the patient's condition

1, 5

14. Which of the following statements indicate that the new nursing graduate understands ways to remain involved professionally? (Select all that apply.) 1. "I am thinking about joining the health committee at my church." 2. "I need to read newspapers, watch news broadcasts, and search the Internet for information related to health." 3. "I will join nursing committees at the hospital after I have completed orientation and better understand the issues affecting nursing." 4. "Nurses do not have very much voice in legislation in Washington, DC, because of the nursing shortage." 5. "I will go back to school as soon as I finish orientation."

1,2,3

15. You are floated to work on a nursing unit where you are given an assignment that is beyond your capability. Which is the best nursing action to take first? 1. Call the nursing supervisor to discuss the situation 2. Discuss the problem with a colleague 3. Leave the nursing unit and go home 4. Say nothing and begin your work

1. Call the nursing supervisor to discuss the situation

Consent Form

Must be signed -necessary for admission to a health care agency and for all procedures -legal duty for the health care provider to disclose material facts in terms the patient is able to understand to make an informed choice.

Unintentional Torts

Negligence and Malpractice

Termination of Pregnancy or Abortion Issues

1973 Roe v. Wade -U.S. Supreme Court ruled that there is a fundamental right to privacy, which includes a woman's right to have an abortion. "dad's friend wade is very quiet" 1989 Webster v. Reproductive Health Services -Some states require viability tests if the fetus is more than 28 weeks' gestational age.

Statutory Laws

Nursing Practice Act (NPA) Criminal Law (felonies or misdeamors) Civil Law -Example: the Nurse Practice Act found in all states. -created by U.S. Congress

Occurrence reporting

Occurrence reporting

1. A nurse is caring for a patient who recently had coronary bypass surgery and now is on the postoperative unit. Which are legal sources of standards of care that the nurse uses to deliver safe health care? (Select all that apply.) 1. Information provided by the head nurse 2. Policies and procedures of the employing hospital 3. State Nurse Practice Act 4. Regulations identified in The Joint Commission manual 5. The American Nurses Association standards of nursing practice

2, 3, 4, 5

2. A nurse is sued for negligence due to failure to monitor a patient appropriately after a procedure. Which of the following statements are correct about this lawsuit? (Select all that apply.) 1. The nurse does not need any representation. 2. The patient must prove injury, damage, or loss occurred. 3. The person filing the lawsuit has to show a compensable damage, such as lost wages, occurred. 4. The patient must prove that a breach in the prevailing standard of care caused an injury. 5. The burden of proof is always the responsibility of the nurse.

2,3,4

6. A nurse notes that an advance directive is on a patient's medical record. Which statement represents the best description of an advance directive guideline that the nurse will follow? 1. A living will allows an appointed person to make health care decisions when the patient is in an incapacitated state. 2. A living will is invoked only when the patient has a terminal condition or is in a persistent vegetative state. 3. The patient cannot make changes in the advance directive once admitted to the hospital. 4. A durable power of attorney for health care is invoked only when the patient has a terminal condition or is in a persistent vegetative state.

2. A living will is invoked only when the patient has a terminal condition or is in a persistent vegetative state.

4. A nurse is planning care for a patient going to surgery. Who is responsible for informing the patient about the surgery along with possible risks, complications, and benefits? 1. Family member 2. Surgeon 3. Nurse 4. Nurse manager

2. Surgeon

13. A home health nurse notices significant bruising on a 2-year-old patient's head, arms, abdomen, and legs. The patient's mother describes the patient's frequent falls. What is the best nursing action for the home health nurse to take? 1. Document her findings and treat the patient 2. Instruct the mother on safe handling of a 2-year-old child 3. Contact a child abuse hotline 4. Discuss this story with a colleague

3. Contact a child abuse hotline

7. A nurse notes that the health care unit keeps a listing of the patient names at the front desk in easy view for health care providers to more efficiently locate the patient. The nurse talks with the nurse manager because this action is a violation of which act? 1. Patient Protection and Affordable Care Act (PPACA) 2. Patient Self-Determination Act (PSDA) 3. Health Insurance Portability and Accountability Act (HIPAA) 4. Emergency Medical Treatment and Active Labor Act

3. Health Insurance Portability and Accountability Act (HIPAA)

3. A nurse stops to help in an emergency at the scene of an accident. The injured party files a suit, and the nurse's employing institution insurance does not cover the nurse. What would probably cover the nurse in this situation? 1. The nurse's automobile insurance 2. The nurse's homeowner's insurance 3. The Good Samaritan law, which grants immunity from suit if there is no gross negligence 4. The Patient Care Partnership, which may grant immunity from suit if the injured party consents

3. The Good Samaritan law, which grants immunity from suit if there is no gross negligence

1. A nurse is caring for a patient who states, "I just want to die." For the nurse to comply with this request, the nurse should discuss: A. living wills. B. assisted suicide. C. passive euthanasia. D. advance directives.

D. advance directives

Sources of Law

Statutory law Regulatory law Common law

The Community Health Accreditation Program (CHAP)and other state and federal standards

•standards require agencies to have guidelines for determining the number (staffing ratios) of nurses required to give care to a specific number of patients.

9. The nurse received a hand-off report at the change of shift in the conference room from the night shift nurse. The nursing student assigned to the nurse asks to review the medical records of the 314 patients assigned to them. The nurse begins assessing the assigned patients and lists the nursing care information for each patient on each individual patient's message board in the patient rooms. The nurse also lists the patients' medical diagnoses on the message board. Later in the day the nurse discusses the plan of care for a patient who is dying with the patient's family. Which of these actions describes a violation of the Health Insurance Portability and Accountability Act (HIPAA)? 1. Discussing patient conditions in the nursing report room at the change of shift 2. Allowing nursing students to review patient charts before caring for patients to whom they are assigned 3. Posting medical information about the patient on a message board in the patient's room 4. Releasing patient information regarding terminal illness to family when the patient has given permission for information to be shared

3. Posting medical information about the patient on a message board in the patient's room

Mental Health Parity Act as Enacted Under PPACA

Strengthens mental health services •PPACA requires parity (the state or condition of being equal) in provision of 10 specific services, including mental health, behavioral health, and substance use services. •Insurers may not discriminate or deny coverage to patients with mental illness because of preexisting conditions. •Patients may remain on their parent's health insurance until they are 26 years old. •Currently, admission of a patient to a mental health unit can occur involuntarily or on a voluntary basis. •If the patient's history and medical records indicate suicidal tendencies, the patient must be kept under supervision.

Emergency Medical Treatment and Active Labor Act

When a patient presents to an emergency department, they must be treated

The Nurse Practice Act

defines legal boundaries of nursing practice in each state -NPA of each state defines the scope of nursing practice and expanded nursing roles, sets education requirements for nurses, and distinguishes between nursing and medical practice. -its a statutory law

Misdemeanor

is a crime that, although injurious, does not inflict serious harm. Ex: parking in no-parking zone. -penalty is usually a monetary fine, forfeiture, or brief imprisonment.

Health Care Proxy or Durable Power of attorney for Health Care (DPAHC)

is a legal document that designates a person or people of one's choosing to make health care decisions when the patient is no longer able to make decisions on his or her own behalf. This agent makes health care treatment decisions on the basis of the patient's wishes.

Cardiopulmonary resuscitation (CPR)

is an emergency treatment provided w/out patient consent. Health Care providers perform CPR on an appropriate patient unless there is a DNR order in the patient's chart.

Negliance

is conduct that falls below the generally accepted standard of care of a reasonably prudent(non-disabled) person.

Standards of Care

legal requirements for nursing practice that describe minimum acceptable nursing care -American Nurses Association (ANA) (2010) develops standards for nursing practice, policy statements, and similar resolutions. These standards outline the scope, function, and role of the nurse in practice. •In a malpractice lawsuit, a nurse's actual conduct is compared to nursing standards of care to determine whether the nurse acted as any reasonably prudent nurse would act under the same or similar circumstances. -The Joint Commission (TJC) (2014) requires accredited hospitals to have written nursing policies and procedures. •In a lawsuit for malpractice or negligence, a nursing expert may testify to the jury about the standards of nursing care as applied to the facts of the case. Nurse experts base their opinions on existing standards of practice established by Nurse Practice Acts, federal and state hospital licensing laws, TJC standards, professional organizations, institutional policies and procedures, job descriptions, and current nursing evidence-based literature.

Living Wills

represent written documents that direct treatment in accordance with a patient's wishes in the event of a terminal illness or condition

Informed Consent

ØAgreement to allow care based on full disclosure of risks, benefits, alternatives, and consequences of refusal ØThe nurse's signature as a witness to the consent means that the patient voluntarily gave consent, the patient's signature is authentic, and the patient appears to be competent to give consent -part of the health care provider-patient relationship -It must be obtained and witnessed when the patient is not under the influence of medication such as opioids. It is not the nurse's responsibility get informed consent. •Key elements of responsibility for the health care provider include the following: •The patient receives an explanation of the procedure or treatment. •The patient receives the names and qualifications of people performing and assisting in the procedure. •The patient receives a description of the serious harm, including death, that may occur as a result of the procedure and anticipated pain and/or discomfort. •The patient receives an explanation of alternative therapies to the proposed procedure/treatment and the risks of doing nothing. •The patient knows that he or she has the right to refuse the procedure/treatment without discontinuing other supportive care. •The patient knows that he or she may refuse the procedure/treatment even after the procedure has begun. •If patients deny understanding or you suspect that they do not understand, notify the health care provider or nursing supervisor. Health care providers must inform a patient refusing surgery or other medical treatment about any harmful consequences of refusal. •Parents are usually the legal guardians of pediatric patients; therefore they typically are the people who sign consent forms for treatment. •Patients with mental illnesses must also give consent. They retain the right to refuse treatment until a court has determined legally that they are incompetent to decide for themselves.

Health Insurance Portability and Accountability Act (HIPAA)

•This law provides rights to patients and protects employees. It protects individual employees from losing their health insurance when changing jobs by providing portability. •It also creates patient right to consent to the use and disclosure of their protected health information, to inspect and copy one's medical record, and to amend mistaken or incomplete information. •It limits who is able to access a patient's record. •Provides confidentiality of a patient's medical information.

Uniform Anatomical Gift Act (UAGA)

•An individual who is at least 18 years of age has the right to make an organ donation. Donors need to make the gift in writing with their signature. In many states, adults sign the back of their driver's license, indicating consent to organ donation. •In most states there is a law requiring that at the time of death a qualified health care provider ask a patient's family members to consider organ or tissue donation. Individuals are approached in the following order: (1) spouse, (2) adult son or daughter, (3) parent, (4) adult brother or sister, (5) grandparent, and (6) guardian. •The National Organ Transplant Act (1984) prohibits the purchase or sale of organs, provides civil and criminal immunity to the hospital and health care provider who perform in accordance with the act, and protects the donor's estate from liability.

Never events

•events are preventable errors, which may include falls, urinary tract infections from improper use of catheters, and pressure ulcers.

Autopsy or Postmortem exam

•may be requested by the patient or patient's family. When the patient's death is not subject to a medical examiner review, consent must be obtained. - The priority for giving consent is (1) the patient, in writing before death; (2) durable power of attorney; (3) surviving spouse; and (4) surviving child, parent, or sibling in the order named.

Common Law

(judicial decisions) results from judicial decisions concerning individual cases. -Most of these revolve around negligence and malpractice

Regulatory Law

(administrative law) defines your duty to report incompetent or unethical nursing conduct to the Board of Nursing -a source of law

Malpractice Insurance

-A contract between the nurse and the insurance company -Provides a defense when a nurse is in a lawsuit involving negligence or malpractice insurance -Nurses covered by institution's insurance while working •The insurance company pays for costs, attorney's fees and settlement, and other related fees generated in the representation of the nurse. •Nurses employed by health care agencies generally are covered by insurance provided by the agency; however, it is important to remember that the lawyer is representing your employer and not you. The insurance provided by the employing agency only covers nurses while they are working within the scope of their employment. •Nurses are also investigated by the State Board of Nursing or Nursing Commission to determine whether the alleged breach in care is a violation of civil regulations associated with their nursing license. Without individual insurance coverage, the nurse will be required to personally pay all costs and attorney fees incurred by him or her in the defense against these claims.

Patient Protection and Affordable Care Act (PPACA)

-Consumer rights and protections -Affordable health care coverage -Increased access to care -Stronger Medicare to improve care fo those most vulnerable in our society •PPACA is also intended to reduce overall care costs to the consumer by: •Providing tax credits. •Increasing insurance company accountability for premiums and rate increases. •Increasing the choices from which patients can choose the right insurer to meet their needs. •Anyone younger than 26 years of age may now continue to receive coverage under his or her parents' insurance plan .•PPACA improves Medicare coverage for vulnerable populations by improving access to care and prescriptions, decreasing costs of medications, extending the life of the Medicare Trust Fund until 2024, and addressing fraud and abuse in billing practices. •PPACA requires parity (the state or condition of being equal) in provision of 10 specific services, including mental health, behavioral health, and substance use services. -Insurers may not discriminate or deny coverage to patients with mental illness because of preexisting conditions. -Patients may remain on their parent's health insurance until they are 26 years old. -Currently, admission of a patient to a mental health unit can occur involuntarily or on a voluntary basis. -If the patient's history and medical records indicate suicidal tendencies, the patient must be kept under supervision.

State Statutory Issues in Nursing Practice

-Licensure -Good Samaritan Laws -Public health laws -The Uniform Determination of Death Act -Autopsy -Death with Dignity or Physician-Assisted Suicide

Advance Directives

-Living wills -Health care proxies or durable power of attorney for health care

Legal Implications in Nursing Practice

-Safe and competent Nursing Practice requires clinical reasoning and an understanding of the legal framework of health care, the specific state's Nurse Practice Act, and the scope and standards of nursing care. -As patient care practice innovations and new health care technologies emerge, the principles of negligence and malpractice liability are being applied to challenging new situations. -Nurses should practice nursing armed with the skills that are the outcomes of informed critical thinking.

Nursing Students

-You are liable if your actions cause harm to patients, as is your instructor, hospital, and college/university. -You are expected to perform as a professional when rendering care. -You must separate your student nurse role from your work as a certified nursing assistant (CNA). •When students work as nursing assistants or nurse's aides when not attending classes, they should not perform tasks that do not appear in a job description for a nurse's aide or assistant. •If someone requests that a student employed in the agency as a nurse's aide perform tasks that he or she is not prepared to complete safely, the student employee needs to bring this information to the supervisor's attention so the task can be assigned to an appropriate health care professional.

"do not resuscitate" (DNR) or "no code" DNR order

-patient refusal of treatment/resuscitation •Documentation that the health care provider has consulted with the patient and/or family is required before attaching a DNR order to the patient's medical record.

Assault

•Assault is an intentional threat toward another person that places the person in reasonable fear of harmful, imminent, or unwelcome contact. No actual contact is required for an assault to occur.

8. Which of the following actions, if performed by a registered nurse, would result in both criminal and administrative law sanctions against the nurse? (Select all that apply.) 1. Taking or selling controlled substances 2. Refusing to provide health care information to a patient's child 3. Reporting suspected abuse and neglect of children 4. Applying physical restraints without a written physician's order 5. Completing an occurrence report on the unit

1, 4

12. You are the night shift nurse caring for a newly admitted patient who appears to be confused. The family asks to see the patient's medical record. What is the priority nursing action? 1. Give the family the record 2. Discuss the issues that concern the family with them 3. Call the nursing supervisor 4. Determine from the medical record if the family has been granted permission by the patient to access his or her medical information

4. Determine from the medical record if the family has been granted permission by the patient to access his or her medical information

11. A homeless man enters the emergency department seeking health care. The health care provider indicates that the patient needs to be transferred to the City Hospital for care. This action is most likely a violation of which of the following laws? 1. Health Insurance Portability and Accountability Act (HIPAA) 2. Americans with Disabilities Act (ADA) 3. Patient Self-Determination Act (PSDA) 4. Emergency Medical Treatment and Active Labor Act (EMTALA) without triage completed

4. Emergency Medical Treatment and Active Labor Act (EMTALA) without triage completed

5. A woman has severe life-threatening injuries and is hemorrhaging following a car accident. The health care provider ordered 2 units of packed red blood cells to treat the woman's anemia. The woman's husband refuses to allow the nurse to give his wife the blood for religious reasons. What is the nurse's responsibility? 1. Obtain a court order to give the blood 2. Coerce the husband into giving the blood 3. Call security and have the husband removed from the hospital 4. More information is needed about the wife's preference and if the husband has her medical power of attorney

4. More information is needed about the wife's preference and if the husband has her medical power of attorney

Risk Management and Quality Assurance

A system of ensuring appropriate nursing care that attempts to identify potential hazards and eliminate them before harm occurs Steps involved: -Identify possible risks -Analyze risks -Act to reduce risks -Evaluate steps taken One tool used in risk management is the incident report or occurrence report Occurrence reporting -Serves as a database for further investigation -Alerts risk management to a potential claim situation Documentation TJC's Universal Protocols Professional involvement

Libel

A written defamation of a person's character, reputation, business, or property rights.

Legal Limits of Nursing

As a nurse you will need to know the legal limits that a nurse can do for nursing practice. -Sources of Law -Standards of Care

Intentional Tort

Assault Battery False Imprisonment

Abandonment and Assignment Issues

Short staffing -Legal problems occur if an inadequate number of nurses will provide care. Floating -Based on census load and patient acuities. -Nurses who float must inform the supervisor of any lack of experience in caring for the type of patients on the nursing unit. They should request and receive an orientation to the unit. Health care providers' orders -Nurses follow orders unless they believe an order is given in error or is harmful. -make sure providers' orders are in writing, dated and timed appropriately, and transcribed correctly.

Felony

a serious offense that results in significant harm to another person or society in general -carry penalties of monetary restitution, imprisoment for greater than 1 year, or deaeth. -Ex: Nurse practice Act violoations: misuse of controlled substance or practicing w/out a license.

Slander

occurs when one speaks falsely about another

False Imprisonment

occurs with unjustified restraint of a person without a legal reason. -This occurs when nurses restrain a patient in a confined area to keep the person from freedom. - False imprisonment requires that the patient be aware of the confinement.

Americans with Disabilities Act

protects rights of people with physical or mental disabilities -fights discrimination -protects health care workers w/disabilites such as human immunodeficiency virus (HIV)

Defamation of Character

publication of false statements that result in damage to a person's reputation -Slander -Libel

3. You are about to administer an oral medication and you question the dosage. You should: A. administer the medication. B. notify the physician. C. withhold the medication. D. document that the dosage appears incorrect.

•Answer: B •Rationale: If you find one to be erroneous or harmful, further clarification from the health care provider is necessary. If the health care provider confirms an order and you still believe that it is inappropriate, use the agency chain of command to inform your direct supervisor.

2. A student nurse employed as a nursing assistant may perform care: A. as learned in school. B. expected of a nurse at that level. C. identified in the hospital's job description. D. requiring technical rather than professional skills.

•Answer: C •Rationale: Student nurses should never perform a task that is not in the job description of the facility with which they work.

Battery

•Battery is any intentional offensive touching without consent or lawful justification. The contact can be harmful to the patient and cause an injury, or it merely can be offensive to the patient's personal dignity. Battery also results if the health care provider performs a procedure that goes beyond the scope of the patient's consent.

Health Information Technology Act (HITECH)

•HITECH expands the principles extended under the HIPAA, especially when a security breach of personal health information (PHI) occurs. •Under the HITECH Act nurses must ensure that patient PHI is not inadvertently conveyed on social media and in particular that protected data are not disclosed other than as permitted by the patient.

Good Samaritan Laws

•Nurses act as Good Samaritans when providing care at the scene of an accident. -All states have Good Samaritan Acts. Provisions may vary among states; however, these laws limit liability and offer legal immunity for nurses who help at the scene of an accident. - At least two states, Minnesota and Vermont, require nurses to stop and help in an emergency. - If you perform a procedure exceeding your scope of practice and for which you have no training, you are liable for injury that may result from that act. -If you leave the patient without properly transferring or handing him or her off to a capable person, you may be liable for patient abandonment and responsible for any injury suffered after you leave him or her.

TJC's Universal Protocol principles:

•Preoperative verification that relevant documents and studies are available before the start of the procedure and that these documents are consistent with the patient's expectations. •Marking the operative site with indelible ink to mark left and right distinction, multiple structures (e.g., fingers), and levels of the spine. •A time-out just before starting the procedure for final verification of the correct patient, procedure, site, and any implants.

Restraints

•The Centers for Medicare and Medicaid Services (CMS), American Nurses Association (ANA), and The Joint Commission (TJC) have set standards for reducing the use of all types of restraints in health care settings. •Restraints can be used (1) only to ensure the physical safety of the patient or other patients, (2) when less restrictive interventions are not successful, and (3) only on the written order of a health care provider. The regulations also describe documentation of restraint use and follow-up assessments.

Death with Dignity or Physician-Assisted Suicide

•The Oregon Death With Dignity Act (1994) was the first statute that permitted physician-assisted suicide. The statute stipulates that competent-yet-terminal patients could make an oral or written request for medication to end their life in a human and dignified manner. Terminal disease is defined as an incurable and irreversible disease that has been medically confirmed and that will, within reasonable medical judgment, produce death within 6 months. •The ANA has held that nurses' participation in assisted suicide violates the code of ethics for nurses. The American Association of Colleges of Nursing (AACN) supports the International Council of Nurses' mandate to ensure an individual's peaceful end of life.

Licensure

•The State Board of Nursing licenses all registered nurses in the state where they practice. -The requirements for licensure vary among states, but most states have minimum educational requirements. -You will be preparing to take the NCLEX-RN®. - The State Board of Nursing suspends or revokes a license if a nurse's conduct violates provisions in the licensing statute on the basis of administrative law rules that implement and enforce the statute.

Malpractice

•is conduct that falls below the generally accepted standard of care of a reasonably prudent person. •Certain criteria are necessary to establish nursing malpractice: 1)The nurse (defendant) owed a duty of care to the patient (plaintiff). 2)The nurse did not carry out or breached that duty. 3)The patient was injured and the nurse's failure to carry out the that duty caused the injury. •The best way for nurses to avoid malpractice is to follow standards of care, give competent health care, and communicate with other health care providers.

Public Health Laws

•protect populations, advocate for the rights of people, regulate health care and health care financing, and ensure professional accountability for care provided. -Under the health code, state legislatures enact statutes that describe the reporting laws for communicable disease, specify necessary school immunizations, and mandate other measures that promote health and reduce health risks in communities. -The Centers for Disease Control and Prevention (CDC) and the Occupational Safety Health Administration (OSHA) provide guidelines on a national level for safe and healthy communities and work environments. •Any health care professional who does not report suspected child abuse or neglect may be liable for civil or criminal legal action.

Civil Law

•protect the rights of individuals and provide for fair and equitable treatment when civil wrongs or violations occur. The consequences of civil law violations are damages in the form of fines or specific performance of good works such as public service. Nursing negligence or malpractice is an example of a civil law violation.

The Uniform Determination of Death Act

•states that health care providers can use the cardiopulmonary definition or the whole brain definition to determine death. -The cardiopulmonary standard requires irreversible cessation of circulatory and respiratory functions. -The whole-brain standard requires irreversible cessation of all function of the entire brain, including the brainstem. -These two definitions facilitate the recovery of organs for transplantation.

A nurse may refuse an assignment when

•when (1) the nurse lacks the knowledge or skill to provide competent care; (2) care exceeding the Nurse Practice Act is expected; (3) health of the nurse or her unborn child is directly threatened by the type of assignment; (4) orientation to the unit has not been completed and safety is at risk; (5) the nurse clearly states and documents a conscientious objection on the basis of moral, ethical, or religious grounds; or (6) the nurse's clinical judgment is impaired as a result of fatigue, resulting in a safety risk for the patient.