Decision Tree for Invoking Safe Harbor and ACCEPTING an Assignment nursing supervisor violation of a nurse's duty to a patient, or a . How has Covid amplified issues to your culture? Washington, DC: National Academy Press. Centers for Disease Control and Prevention (2013). This encompasses a wide range of potentially dangerous situations and criminal activity, including tampering with medical records, putting the patient, the nurse or another persons life in danger, or committing a crime of some sort. Solving tough problems through innovation and proven methodology. Since the beginning of the profession, through individual and collective efforts, nurses have changed practice through policy most policy work involves collaboration among nurses and other stakeholders. Boards of nursing will discipline nurses and leaders who knowingly allow or foster unsafe practices. In your situation, it is absolutely unwise to assign you to direct patient care for any patients you do not feel qualified to care for. What do you do? Code of ethics with interpretive statements. Medical Care, 45(12), 1195-1204. But a nurse can invoke whats known as nursing safe harbor that absolves them of any liability when forced to engage in an activity that could put their career at risk. Yours is a specialization and you cant be transplanted to another area imagine if any of the adult care nurses were suddenly told they had to care for NICU patients without training and supervision. This includes protections for whistleblowers. Insurance companies pay the price for HAIs. The statute was implemented in 2004. Date/Time of Request: 3. To comment please, Comments on Medscape are moderated and should be professional in tone and on topic. The Department of State Health Services fined the hospital the maximum allowable amount of $1,300 (Thomas & Willman, 2012). This law allows up to $25,000 per occurrence to deter retaliatory behavior (Texas Senate Bill No. We then offer exemplars that illustrate policies that regulate the environment of practice, such as nurse staffing, musculoskeletal injury prevention, and failure to advocate, and discuss needed protections, including whistleblower protections. For example, dissatisfied with the staffing by patient acuity model legislated in the early 1990s, (Coffman, Seago, Spetz, 2002) members of the California Nurses Association successfully pressed 164 legislators to pass a prescriptive bill specifying the maximum number of patients to be assigned to a registered nurse in each patient care area (California Assembly Bill No. Put your objections or refusal in writing. Nurses are warm, compassionate and forgiving to a fault. The profession of nursing has changed significantly in the 160 years since Florence Nightingales day, but her words still ring true today, Unless we are making progress in our nursing every year, every month, every week, take my word for it we are going back (Nightingale, 1914, p. 1). General Information About Safe Harbor; The Texas Board of Nursing (BON or Board) has safe harbor nursing peer review forms available to make the process faster and easier for a nurse who believes he/she is being asked to accept an unsafe assignment, engage in conduct beyond his/her scope of practice, or engage in unprofessional or illegal conduct. Recently our hospital has opened an adult unit as an overflow from the University hospital. Safe Harbor (SH): A process that protects a nurse from employer retaliation, suspension, termination, discipline, . Nurses are not always in control of the care they provide, so its important that everyone understands the terms of safe harbor and when it may be invoked. Good luck! Neither are nurses legal, professional, and ethical duties. Many nurses may remember the times before cars had seatbelts and smoking in the nurses lounge was a common practice. (Dressner & Kissinger, 2018). Nurse staffing, burnout, and health careassociated infection. The Texas law applies to employers of eight or more nurses. For example, the Texas State Board of Pharmacy (TSBP) . The supervisor can be legally held liable for failure to properly assign, supervise, delegate and so could the hospital in the event of patient injury or death. Other states have passed legislation (ANA, 2019) with an alternative policy approach requiring hospitals to engage nurse staffing committees in the determination of appropriate staffing levels. doi: 10.1097/01.NNA.0000312773.42352.d7, American Nurses Association. This is often related to the ethical concerns arising from conflicting values and obligations inherent in the disaster work environment. Even if you have never been in questionable situation, you should know your organizations policies and your states laws and regulations regarding refusing an assignment. Occupational injuries and illnesses among registered nurses. New Mexico's law was inspired by a Texas law. Think about it this way: if you were a new airplane mechanic and were assigned to work solo on a new type of engine that you havent seen before, knowing that the plane was due to fly over 300 passengers and crew in 2 hours, would you do it without objection? (2007). Aiken, L. H., Cimiotti, J. P., Sloane, D. M., Smith, H. L., Flynn, L., & Neff, D. F. (2012). Policy frames nursing practice in the most fundamental way: through state nurse practice acts (NPA) which date back over one hundred years in many states. During the most recent legislative session, TNA leaders negotiated bill language with the Texas Hospital Association that would have required workplace violence prevention plans with input from direct care nurses. For example, a primary care physician and a specialist to whom the . The federal level (CMS) requires certain staffing too. An estimated 12-18% of nurses leave the profession due to chronic back pain (Nelson & Baptiste, 2006). (2019). The NDNQI provided one of the first databases of patient and nurse outcome indicators and it is currently the only national database containing unit level data regarding nurse sensitive indicators. Your unit has a 6-bed intermediate care or step-down unit that is staffed at a "1 nurse to 3 patients" ratio. Nursing safe harbor is a law that nurses can use to absolve themselves of liability when forced to commit an act that the nurse believes violates Texas Board Statutes and Rules. Since the beginning of the profession, through individual and collective efforts, nurses have changed practice through policyAlthough Ms. Nightingale was often successful in single-handedly influencing policy through her relationships with military and hospital leaders, most policy work involves collaboration among nurses and other stakeholders. .resBTN a.cpBtn { text-align: center; height: 35px; line-height: 35px;margin: 20px auto 20px;} 192: Section 301.413(b-1). (2019). Thank you! Required fields are marked *. Effects of hospital care environment on patient mortality and nurse outcomes. Ellen began her clinical practice in neuroscience nursing and for the past 20 years has focused on healthcare quality across the continuum of care from acute care hospitals, to community-based mental health, home care, and hospice. NPAs have not remained stagnant over the past century, rather they have evolved but only with the active involvement of nurses in legislative efforts to change statute and update policies related to nursing practice. Members with any question (not just those relating to practice) can take advantage of the online Member Helpline. CORONAVIRUS HOTLINE 855.487.7221. deconservices@cleanharbors.com. Or go, try, risk making a mistake, and hope for the best? She doesn't think she can provide safe care to sick neonates, and says so to the supervisor, who tells her to go to the neonatal unit anyway. doi: 10.1097/01.NNA.0000420390.87789.67, Aiken, L. H., Clarke, S. P., Sloane, D. M., Lake E. T., & Cheney T. (2008). Every nurse should be aware of the statutes and rules governing their profession. Several changes in the healthcare industry have influenced the advocacy efforts of individual nurses and nursing organizations. American Nurses Association. Nurse practice acts guide and govern nursing practice. And now nurses can also use oral safe harbor when they are unable to stop what they are doing to fill out forms. Cite this: A 'Safe Harbor' for Unsafe Nursing Assignments-Medscape-Apr26,2019. JOIN TNA AND ANA TODAY, 3/1/2023TPAPN Lunch and Learn: Substance Use Disorder and Mental Health in Nursing, 3/28/2023TPAPN Peer Support Partner Information Session, 3/31/2023Nuts & Bolts of Peer Review Workshop, 4/18/2023TPAPN Peer Support Partner Information Session, Texas Affiliate of ANA | 4807 Spicewood Springs Rd., Bldg 3, Suite 100, Austin, TX 78759, 800.862.2022 | 512.452.0645 | tna@texasnurses.org, Association Management Software Powered by, TPAPN Lunch and Learn: Substance Use Disorder and Mental Health in Nursing, TPAPN Peer Support Partner Information Session. However, we recognize that there are stories from every state that highlight the valuable work of many nurses that illustrate individual and collective nursing organization advocacy. She received a BSN from University of Detroit Mercy, magna cum laude, an MSN in adult psychiatric-mental health nursing from Wayne State University, and a PhD in nursing from University of Texas at Austin where she was recognized as the outstanding doctoral student. As we begin 2020, designated by the World Health Organization ([WHO], 2019) as the Year of the Nurse and Midwife, policy change remains among the most effective approaches to create the circumstances for the right thing to be done. The nurse may accept the assignment and be protected from retaliation from the employer and disciplinary action from the board of nursing pending the committee's decision. A brief history of Florence Nightingale and her real legacy, a revolution in public health. The completion of this project is a great example that through the dedication and generosity of all the partners who are working together, we are succeeding in finding concrete solutions to . This report revealed disturbing insights into the prevalence of medical errors in healthcare and the consequences of those errors. They are not providing any cross training at all. What are the nurse's options here? Bear, EdD, MSN, RN, CNE; Mindy L. Schaffner, PhD, MSN, RN, CNS. The Safe Harbor Rule (SHPR) is a nursing peer review process that any type of nurse (licensed vocational nurse or registered nurse) can initiate in good faith whenever asked to take part in assignments or conduct that might result in one or more violations of Texas Board of Nursing rules and statutes. However, there is a large majority who have never experienced working in disaster situations such as hurricanes, mass shootings, or disease outbreaks and therefore may not be aware of their role in the emergency preparedness process and what they can do for themselves. When a potential situation arises either at the beginning of the shift or later on if conditions deteriorate try to identify exactly what the problem is. (n.d.). Texas Senate Bill No. Retrieved from https://www.bon.texas.gov/pdfs/law_rules_pdfs/nursing_practice_act_pdfs/NPA2019.pdf, Texas Constitution and Statutes. This assistance is covered by the SHQ (90%) and the City of Montral . The safe harbor protects certain arrangements when an individual or entity agrees to refer a patient to another individual or entity for specialty services in return for the party receiving the referral to refer the patient back at a certain time or under certain circumstances. This example represents a missed opportunity for nurses to change practice through policy. You must declare any conflicts of interest related to your comments and responses. Contact your BON for guidance, and if you have your own malpractice insurance (and I believe every nurse should, beyond any coverage provided by the employer) contact the carriers risk management service for additional perspective. This protects them from facing punitive measures from their employer, losing their nursing license or being sued in court for putting a patients life in danger. We offer these to affirm the work of these nurses and organizations as we celebrate nurses this year. Although the organizational policy changes that result from implementation of grant programs may help protect the nurses who work the facilities awarded grant funds, widespread protections remain elusive despite a decade of advocacy. Texas Senate Bill No. Texas was the first state to have safe patient handling and movement policies enacted in legislation. Decision Tree for Invoking Safe Harbor and ACCEPTING an Assignment nursing supervisor violation of a nurse's duty to a patient, or a . A few years later, nineteen nurses convened on February 22, 1907 to establish the Graduate Nurses Association of Texas, later renamed the Texas Nurses Association (TNA). Board Rule 217.20 is the Board's rule concerning safe harbor nursing peer review, and 217.20(e) outlines the requirements the nurse must meet in order to secure the protections, . We are looking for someone to be able to work closely with our business end . The National Database of Nursing Quality IndicatorsTM (NDNQI). Consider another situation: You are an experienced nurse. (2019). She received a BSN from University of Detroit – Mercy, magna cum laude, an MSN in adult psychiatric-mental health nursing from Wayne State University, and a PhD in nursing from University of Texas at Austin where she was recognized as the outstanding doctoral student. Nurses dont always have a lot of authority on the floor, so they need to learn how to protect themselves if someone asks them to do something that goes against their ethics or the law. The American Nurses Association ([ANA], n.d., para. Retrieved from http://ojin.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Volume92004/No3Sept04/HandleWithCare.html, Dressner, M. & Kissinger, S. P. (2018). Be polite and factual when you follow the chain of command through the charge nurse, unit leader, or nursing office. Decades of research have confirmed the relationship between nurse staffing and patient outcomes such as mortality (Aiken et al., 2012; Aiken, Clarke, Sloane, Lake, & Cheney, 2008), healthcare-associated infections (Cimiotti, Aiken, Sloane, & Wu, 2012), financial, and nurse outcomes (Unruh, 2008). legislators had difficulty appreciating the reality of violence in healthcare settings. Cindy’s nursing career spans advanced practice, chief nurse executive, and academic roles. The BON Comprehensive Written Request for Safe Harbor Nursing Peer Review Form is a sample form that may be used to document the more in-depth information that the nurse must put in writing before leaving the work setting at the end of the work period. Example of a Safe Harbor To illustrate a safe harbor accounting method that helps a tax filer sidestep a tax regulation, assume a firm is losing money and cannot thus claim an investment. R. L., Shamliyan, T. A, Mueller, C., Duval, S., & Wilt, T. J. Objections must be in writing so check to see if your facility or state has a form and keep several blank copies in your locker or backpack. This article will begin by briefly addressing the role of nurses in advocacy to advance professional practice, and offer background information about the changing healthcare industry that has influenced the example of advocacy we discuss. In addition, rising obesity rates means that nurses are caring for patients who are heavier and have a higher rate of comorbid conditions. In Texas, a nurse may invoke safe harbor when the nurse believes he or she has been given an unsafe assignment by filling out a lengthy form, and a peer review committee at the facility must make a determination about the situation within 14 days. Legal expert Martin Chitwood weighs in about nursing safe harbor and how nurses can use it to protect themselves in risky situations. I have worked NICU for 31 years. Thank you for this article. The law applies to entities having three or more nurses that are licensed by the department of health to provide healthcare on their premises. They are at the service of the patient and the doctor or another medical supervisor. We conclude by considering the common thread among these exemplars. Given the outcome and scope of the outcomes of successful advocacy, and the failure to advocate discussed above, it is important to address the need for advocacy protections. Texas took a slightly different approach to the problem. As gaps in protection are identified, nurses work to address them through policy change. Texas Nursing, 89(3), 7-9, 17. Workplace violence. Location of requested conduct/assignment: 4. You submit it to the BON. (Read the story of how one nurse worked through TNA to make this possible.). Small, H. (2017). working mandatory overtime, accepting expanded patient assignments, etc. Click the topic below to receive emails when new articles are available. All rights reserved. For example, prior to 2019, nurses were required to invoke safe harbor in writing and notify the supervisor to receive the protections from employer discipline or board sanction. In Texas, it is called the safe harbor provision and other states, although they may not use that term, have similar policies or statutory wording. What do you do? To this end, the Texas Nurses Foundation has a dissertation grant program to support research on the impact of nursing policies in Texas. Initially, outcomes data related to nurse staffing was sparse.Measurements of quality shifted away from an interest in structure and process, and instead targeted outcomes: patient, staff, and financial. This database includes measures directly related to nursing care and patient outcomes (Montalvo, 2007) such as: nursing hours per patient days; hospital-acquired infections and pressure ulcers; and skill mix (percent of total nursing hours supplied by different types of direct care providers). of nursing care for a defined work period in a defined work setting, including the specified functions, duties, practitioner orders, supervisory directives and amount of . Evidence-based practices for safe patient handling and movement. (2015). The unit also has 18 general medical beds. Texas Senate Bill No. Nurses have an ethical imperative to engage in policy.Advocacy as an Ethical DutyNurses have an ethical imperative to engage in policy. Since the beginning of the profession, through individual and collective efforts, nurses have changed practice through policy by addressing systemic barriers to optimal patient care and healthy environments through establishment of standards, regulations, and policy. 61-3A-1. If were talking about a full-shift assignment, the facility is setting itself up for a malpractice suit and likely sanctions from the licensing/accrediting body, which could result in large fines, even revocation of Medicare status. Cates, A. Citation: Martin, E., Zolnierek, C., (January 31, 2020) "Beyond the Nurse Practice Act: Making a Difference through Advocacy" OJIN: The Online Journal of Issues in Nursing Vol. RN TO FNP TRANSITION | The First 6 Months. Nurses can invoke safe harbor, in good faith, to protect their licenses if they find themselves in compromised practice situations where it is not in the best interest of patients for them to accept an assignment, e.g. Adequate coverage runs about $10-12/month and many policies include a legal representation benefit if your BON tries to discipline you. Journal of Nursing Administration, 38(5): 223229. Nurses can invoke safe harbor, in good faith, to protect their licenses if they find themselves in compromised practice situations where it is not in the best interest of patients for them to accept an assignment, e.g. Here is an example of how the Texas law can work successfully[1]: New Mexico and Texas are the only two states so far that offer a "safe harbor" for nurses who find themselves with possibly unsafe assignments or orders. (2016). I agree! Nurse staffing and patient, nurse, and financial outcomes. 5 pages, 2066 words Retrieved from http://ojin.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Volume122007/No3Sept07/NursingWorkforceCharacteristics.html, Jones, T., Bae, S. H., & Murry, N. (2015). Why nurses need whistleblower protection. This provision is called Safe Harbor. No nurse, from a patient safety and legal liability standpoint, should ever be assigned primary care responsibility for patients that they are unqualified to care for yes, your license says you MAY care for these patients BUT that is only AFTER youve had training and supervision. Often policy change involves an incremental approach that requires persistence.An example of incremental work is the many efforts to address workplace violence. She is active in policy development, actively assisting policy committees in analyzing issues and developing policy positions. Board of nursing rules outline the procedures nurses must follow to access these protections. Licensure eligibility criteria and the first licensure exam were developed in 1904. You fill out a form that basically says that your work environment is unsafe and you will continue to care for your patients to the best of your ability, but are not held responsible for mistakes that are made. Unfortunately, many nurses and many leaders will answer the question with some form of suck it up and do the best you can. And while I know that questioning an assignment, let alone refusing it, is hard, this is exactly what you must consider doing. As chief executive of the Texas Nurses Association, Cindy leads the strategic operations of the Texas Nurses Association, a professional membership organization of registered nurses that empowers Texas Nurses to advance the profession. Examples: due to staffing and/or acuity of the patient(s). Notes on Nursing (1969 ed.). Evidence about workplace violence was needed to understand the scope of the problem in Texas as well. To invoke safe harbor, the nurse must notify the supervisor in writing that they are invoking safe harbor. In 2020, the Year of the Nurse and Midwife, let every nurse and professional nursing organization continue the forward progress that advocacy supports.Nurses know that a culture supporting collaborative, interdisciplinary practice that encourages both identification and reporting of problems and barriers to care delivery leads to optimum patient and nurse outcomes. However, changing practice through policy does not stop with the NPA. Thank you for your comment. It is one thing to have patients on a unit and one goes to radiology. Protections can be eroded through subsequent legislation or agency rules, and enforcement mechanisms may be weak or non-existent. Yet, legislators had difficulty appreciating the reality of violence in healthcare settings (D. Howard, personal communication, February 5, 2015). When you arrive for the day shift, you have a full house and you discover that one of the two step-down nurses is out sick. (15) Safe Harbor--A process that protects a nurse from employer retaliation, suspension, termination, discipline, discrimination, and licensure sanction when a nurse makes a good . She collected, analyzed, and presented evidence to decision-makers on improved nutrition and hydration, sanitation, and ventilation for hospitalized patients (Kudzma, 2006). Remember that it could be you or a loved one in the patient room someday. 394. Effects of nurse staffing and nurse education on patient deaths in hospitals with different nurse work environments. I dont understand why any supervisor would put him or herself, the facility, the patients, and the nurses in this situation. Texas Nursing Voice, 7(3): 1, 3-4. You cannot be responsible for patients in 2 different locations (units, departments) at the same time UNLESS a qualified provider is covering the other patient. Cindy Zolnierek, PhD, RN, CAEEmail: cdzolnierek@texasnurses.org. The nursing supervisor calls and tells you to go to the oncology unit youve been floated. The Texas Nursing Practice Actincludes several advocacy protections for nurses. Retrieved from https://statutes.capitol.texas.gov/Docs/HS/htm/HS.257.htm, Texas Department of State Health Services. The Texas Nursing Practice Actincludes several advocacy protections for nurses (Texas Occupations Code Chapter 301, 303, 304, 2019). The most recent example is a nurse who contacted the TNA practice hotline because she was retaliated against for speaking up for patient safety. She is also a licensed attorney with her Juris Doctor degree from the University of Tennessee. An existing policy of enhanced criminal penalties for assaults against first responders, such as peace officers, firefighters, and emergency medical service workers (which elevated the seriousness of the offense from a misdemeanor to a felony) inspired a similar approach to deter violence against nurses. With the increasing availability of information about preventable errors and complications of hospital care, particularly those related to nursing care, hospitals were called to higher levels of accountability for patient outcomes. Dont hope that everything will be alright. You not only have all 6 step-down patients, you are now charge over the other 18 beds. Although both bills failed to pass in 2011 (Willmann, 2011), similar legislation enhancing penalties for assault of emergency department personnel passed in the next legislative session (Willmann, 2013). Often policy change involves an incremental approach that requires persistence. Black (2011) described what, at the time, was thought to be the largest documented patient nosocomial bloodborne pathogen exposure due to inappropriate reuse of equipment and syringes intended for single use. Over the years, the core values of nursing have remained constant and principles upheld, while specific concerns have evolved and been clarified. Recognizing this gap in protection, TNA worked with Representative Stephanie Klick, RN, one of two nurses in the Texas Legislature, to pass House Bill 2410 Oral Safe Harbor (Texas House Bill No. HB 2696 provided authority for the Texas Center of Nursing Workforce Studies to conduct a survey both healthcare organizations and nurses about their experiences with workplace violence (Cates, 2015). Texas was the first state to have safe patient handling and movement policies enacted in legislation. They participate in operationalizing and implementing emergency preparedness plans within their organizations, they work additional hours, they volunteer at shelters for displaced medically fragile persons, and they coordinate medical supplies, blood donations and other vital resources. Then radiology is taking care of the patient FOR A SHORT TIME. most policy work involves collaboration among nurses and other stakeholders.Nursing practice is regulated at the state level, therefore most of the exemplars in this article are from Texas, our state. TNA developed a strategy to obtain funding for a statewide study of health care organizations (including hospitals, free-standing emergency centers, long term care facilities and homecare agencies), to validate the extent of the problem and provide the foundation for future violence prevention initiatives. iPhone and App Store are registered trademarks of Apple Inc. Google Play and the Google Play logo are trademarks of Google LLC. 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