The risks are not only damaging to the health of nurses and patients, but also are costly in terms workers compensation insurance and nurse turnover. 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. 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. Remember, the TNA practice hotline line is an available resource for nurses with questions related to nursing practice. The law allows a nurse to reject an assignment on the basis of the nurse's assessment of his or her education, knowledge, competence, or experience and the nurse's immediate assessment of the risk for patient safety, or violation of the Nurse Practice Act or Board of Nursing rules. To this end, the Texas Nurses Foundation has a dissertation grant program to support research on the impact of nursing policies in Texas. Revision of the code in 1995 expanded it to include social ethics, global concerns, and emphasis on the important role of nurses in health policy. Several changes in the healthcare industry have influenced the advocacy efforts of individual nurses and nursing organizations. 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. Please confirm that you would like to log out of Medscape. Brief explanation of why invoking Safe Harbor (It may be helpful to review rules 217.11 and 217.12): Signature(s) of Nurse(s) Invoking Safe Harbor: In addition, the ANAs Code of Ethics for Nurses (2001) spells out the RNs accountability for judgments made and actions taken in the course of nursing practice, irrespective of health care organizations policies or providers directives, (Provision 4). Nurse researchers are working to describe these relationships and provide guidance for effective staffing models. A place where registered nurses and nurse practitioners offer helpful videos and articles and advice to other nurses. 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. She encouraged all nursing associations to make violence prevention a top-priority and urged hospital leaders to adopt zero-tolerance policies. Kohn, L. T., Corrigan, J., & Donaldson, M. S. What are the nurse's options here? Good luck! doi: 10.1097/01.NNA.0000420390.87789.67, Aiken, L. H., Clarke, S. P., Sloane, D. M., Lake E. T., & Cheney T. (2008). Licensure eligibility criteria and the first licensure exam were developed in 1904. I work at a Childrens and Womens hospital. Zolnierek, C. (2019). Nightingale, F. (1860). She has authored numerous publications focusing on nursing practice, advocacy, and care of persons with serious mental illness. Required fields are marked *. Texas Senate Bill No. A joint investigation by federal and state agencies revealed violation of standard infection control practices. Care for the Caregiver resources are available to help nurses balance care for patients with care for family and self. The most recent iteration of the code (ANA, 2015) addresses the ethical imperative for engagement in policy. (2007). The nursing supervisor calls and tells you to go to the oncology unit youve been floated. American Journal of Nursing, 110(3), 11. doi: 10.1097/01.NAJ.0000368933.60442.41, Texas Board of Nursing. What if the patient or supervisor asks a nurse to do something that would violate Board Statutes and Rules, such as falsifying medical records, performing a procedure that could harm the patient, or even assisting in criminal activity? Please see our, You are being redirected to Medscape Education, Challenges to Adolescent HPV Vaccination and Implementation of Evidence-Based Interventions to Promote Vaccine Uptake During the COVID-19 Pandemic: HPV Is Probably Not at the Top of Our List. For example, a telemetry unit in one small community hospital can compare its pressure ulcer and vacancy rates to a similar unit in another community hospital. For the first time, patient outcomes could be specifically mapped to nursing care, not just by morbidity or medical complications, but by outcomes that are specifically amenable to nursing management and intervention. Journal of Nursing Regulation, 3(3), 19-23. https://doi.org/10.1016/S2155-8256(15)30203-9, Unruh, L. (2008). Your email address will not be published. The nursing office says it has no one to help you for at least another 4 hours, if that. She says you are just going to help out, do general basic nursing care; the regular staff nurses will handle everything else. 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. With the increasing body of evidence documenting the relationship between nurse staffing and patient outcomes, several states have passed legislation requiring organizations to adopt more specific policies and practices. As gaps in protection are identified, nurses work to address them through policy change. Washington, DC: American Nurses Publishing. The facility may not retaliate against the nurse who invokes the safe harbor. (2012). Executive Board designates 2020 as the Year of the Nurse and Midwife. Retrieved from https://www.who.int/hrh/news/2019/2020year-of-nurses/en. (2007). While many nurses recognized the reuse practice as inconsistent with safe infection control practices, complacency among coworkers and fear of retaliation inhibited reporting of concerns. Online Journal of Issues in Nursing, 9(3). I am so sorry you are going through this. 2410, 2019), which allows nurses to invoke safe harbor orally in situations where patient needs prevents nurses from leaving the beside to complete safe harbor forms. Texas was the first state to have safe patient handling and movement policies enacted in legislation.The national Handle with Care campaign, launched by ANA in 2003 to engage members of the healthcare industry in back injury prevention, spurred advocacy efforts to change policy (de Castro, 2004). Taylor, J. L. (2010). Kane. These exemplars describe the impact of nurse advocacy to influence policy that affects nursing practice or the practice environment. 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. A nurse may not feel as if they have the option of saying no or refusing to engage in these kinds of situations, so invoking safe harbor may be their only choice. Several changes in the healthcare industry have influenced the advocacy efforts of individual nurses and nursing organizations.Hospitals were compelled to focus specifically on safety when in 1999 the Institute of Medicine (IOM) released its groundbreaking report, To Err is Human (Kohn, Corrigan, & Donaldson, 2000). Nightingales post-war work on hospital reform is among her most lasting accomplishments (Small, 2017). I reference the ANA Code often with my students! Orthopedic Nursing, 25(6), 366-379. Cates, A. The Figure offers additional information about Texas patient advocacy and whistleblower protections. Key Words: nurse, nurse advocacy, health policy, legislation, nurse practice act, whistleblower. This report revealed disturbing insights into the prevalence of medical errors in healthcare and the consequences of those errors. (2004). (2019). American Journal of Nursing, 111(6), 26-35. doi: 10.1097/01.NAJ.0000398537.06542.c0, Brigham, C. J. Location of requested conduct/assignment: 4. She has authored numerous publications focusing on nursing practice, advocacy, and care of persons with serious mental illness. Nurse(s) Name(s) invoking Safe Harbor: 2. Frequent bending and standing contributes to fatigue and may increase the risk of slips of falls. Online Journal of Issues in Nursing, 12(3). Board of nursing rules outline the procedures nurses must follow to access these protections. B. Nurses who accept or make assignments must consider patient safety. In the meantime, make sure you document what you were told, who told you, what they said verbatim, when, etc. This website also contains material copyrighted by 3rd parties. Neither are nurses legal, professional, and ethical duties. Or go, try, risk making a mistake, and hope for the best? Your unit has a 6-bed intermediate care or step-down unit that is staffed at a 1 nurse to 3 patients ratio. https://www.youtube.com/watch?v=CD7dqj1iPwQ, 10 Questions an Operating Room Registered Nurse Candidate Should Ask the Interviewer. Dont hope that everything will be alright. Imagine this scenario: A nurse who has worked for 2 years in an adult medical-surgical unit reports for work and learns that she is assigned to work in neonatal intensive care that day. This is a free resource for all Texas nurses: 1.800.862.2022, ext.132. Handle with care: The American Nurses Associations campaign to address work-related musculoskeletal disorders. Texas Board of Nursing (TBON, n.d.a) clarifies Safe Harbor as a nursing peer review process the nurse may initiate, under good faith, when asked to engage in assignments or conduct the nurse believes to violate Standards of Practice, Duty to Patient, or . New Mexico's law was inspired by a Texas law. American Nurses Association. 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. The nurse who invokes safe harbor may not leave the work setting without collaborating with the supervisor. 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Unfortunately, the significance of nurse advocacy in protecting patients from harm is perhaps best illustrated in an example in which advocacy failed and patients were harmed. Nurses have an ethical imperative to engage in policy.Advocacy as an Ethical DutyNurses have an ethical imperative to engage in policy. There are three variants; a typed, drawn or uploaded signature. I am concerned for the patients safety and I need your help to find a safer way to take care of these patients. I cannot accept this assignment because my lack of knowledge or experience will put these patients at risk of harm. 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. Safe patient handling and mobility. A nurse must invoke safe harbor before engaging the act in question. (2011). We 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 in our state. Thank you for your comment. Nursing Practice Act, Nursing Peer Review, & Nurse Licensure Compact: Texas Occupations Code. Musculoskeletal Injury PreventionPatient transfers, lifting, and handling are physically demanding and present clear risk for both the patient and the nurse. 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. You have a duty to protect the patients and the general public. 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, . This bill did not pass, and work is ongoing to ensure healthcare facilities implement robust strategies that protect not only nurses but all employees. Cite this: A 'Safe Harbor' for Unsafe Nursing Assignments-Medscape-Apr26,2019. 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. If you are a leader, do not punish the nurse objecting or refusing the assignment. We conclude by considering the common thread among these exemplars. 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. Acqeisising and accepting unsafe or inappropriate practices is equivalent to condoning unsafe practice. (Prov. (2019, January 30). Notes on Nursing (1969 ed.). 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). This example represents a missed opportunity for nurses to change practice through policy. 394, 1999). Effects of hospital care environment on patient mortality and nurse outcomes. However, changing practice through policy does not stop with the NPA. 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. 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. As gaps in protection are identified, nurses work to address them through policy change.As gaps in protection are identified, nurses work to address them through policy change. Nurses and other front-line health care works will be the most vulnerable populations to the virus. Nurses have been advocating for change since the day Florence Nightingale penned an urgent missive to the Secretary of State for War on the need for trained nurses to care for the wounded soldiers in the Crimea. In the second situation, one of the attending physicians saw what was happening and went to the nursing office himself. Examples: due to staffing and/or acuity of the patient(s). Nurse StaffingStaffing involves a process of matching and providing staff resources to patient care needs. Document carefully and use the experience to identify potential staff or policy needs and ways to respond to future such situations. When nurses find themselves in compromising situations, there are resources available to them and laws in place to protect the nurse and their license. After Mitchell and Galle were exonerated in a jury trial, nurse advocates went to work to strengthen nurse protections. State facts, include the date and time, and why you are refusing or objecting. Remember that it could be you or a loved one in the patient room someday. Be polite and factual when you follow the chain of command through the charge nurse, unit leader, or nursing office. Successful advocacy requires the identification of concerns by individual nurses, coupled with leadership and persistence of nursing organizations with strength in numbers and a policy agenda. A brief history of Florence Nightingale and her real legacy, a revolution in public health. Several changes in the healthcare industry have influenced the advocacy efforts of individual nurses and nursing organizations. Retrieved from https://tshaonline.org/handbook/online/articles/sat02, California Legislative Information. Put your objections or refusal in writing. 192, 2011). (2005). Simultaneously, they may be worried about their family and loved ones. My head nurse, who was off that day, phoned and accused me of deliberately trying to make her look bad to senior management. Retrieved from https://www.bon.texas.gov/pdfs/law_rules_pdfs/nursing_practice_act_pdfs/NPA2019.pdf, Texas Constitution and Statutes. Journal of Nursing Administration, 42(10), Supplement: S10S16. For the first time, patient outcomes could be specifically mapped to nursing care Nurse staffing is resource intensive and is the largest component of hospital operational budgets. 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. Protections can be eroded through subsequent legislation or agency rules, and enforcement mechanisms may be weak or non-existent.In sum, the need for evaluation of policies is vital. 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. Commenting is limited to medical professionals. If you dont have your own malpractice/professional liability insurance, you should invest in coverage immediately because the facility will likely try to shift blame for any patient injuries or deaths to the individual nurse. Our content creators range from New Grad Nurses to Experienced Registered Nurses and Nurse Practitioners. Where creative models of care to reduce costs dominated dialogue around nurse staffing in the 1990s, attention was cued to staffing outcomes following the IOM report. You submit it to the BON. A nurse may invoke safe harbor to err on the side of caution whenever they feel that their actions as requested by a patient or supervisor may violate Board Statures and Rules. She is active in policy development, actively assisting policy committees in analyzing issues and developing policy positions. 192: Section 301.413(b-1). 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. weighs in about nursing safe harbor and how nurses can use it to protect themselves in risky situations. Share cases and questions with Physicians on Medscape Consult. Setting standards for nursing education was an important component of early nursing regulation (Russell, 2012). Effects of nurse staffing and nurse education on patient deaths in hospitals with different nurse work environments. Kudzma, E. C. (2006). Legal expert Martin Chitwood weighs in about nursing safe harbor and how nurses can use it to protect themselves in risky situations. iPhone and App Store are registered trademarks of Apple Inc. Google Play and the Google Play logo are trademarks of Google LLC. Evidence-based practices for safe patient handling and movement. It is not enough to say that we want what is best for our patients; we must also do what is best for our patients. Nursing workload and hospital work environment variables, including culture, have a significant impact on the ability of the nurse to provide safe and appropriate care (Kane et al., 2007; Unruh, 2008). Adequate coverage runs about $10-12/month and many policies include a legal representation benefit if your BON tries to discipline you. A CNA is not legally sufficient full-shift coverage for patients assigned to an RN. (2016). To comment please, Comments on Medscape are moderated and should be professional in tone and on topic. Every nurse should be aware of the statutes and rules governing their profession. 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. please help the nurses reason legally to this unsafe patient services. 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). Nurses have an ethical imperative to engage in policy. Nightingale, F. (1914). An estimated 12-18% of nurses leave the profession due to chronic back pain (Nelson & Baptiste, 2006). working mandatory overtime, accepting expanded patient assignments, etc. In 2019, legislation supported by NLAC as well as the Texas Hospital Association was proposed to establish Violence Prevention Committees within healthcare organizations (HB 2980); the effort failed (Zolnierek, 2019). Recently our hospital has opened an adult unit as an overflow from the University hospital. The facility must have a process by which to further assess the situation. 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). Texas Nursing Voice, 5(3):1, 4. Then the nursing office pulls one of the two RNs on the rest of the unit, leaving two LPNs and a tech for the 18 beds. Solving tough problems through innovation and proven methodology. Consider another situation: You are an experienced nurse. Often policy change involves an incremental approach that requires persistence.An example of incremental work is the many efforts to address workplace violence. Nurses are warm, compassionate and forgiving to a fault. The Texas Nursing Practice Actincludes several advocacy protections for nurses (Texas Occupations Code Chapter 301, 303, 304, 2019). A study examining the effect of Texas staffing legislation (Texas Senate Bill 476, 2009) found that hospitals with higher staffing levels did not significantly change after the legislation and hospitals the lowest staffing levels prior to the legislation increased staffing (Jones, Bae, and Murry, 2015). Cindy Zolnierek, PhD, RN, CAEEmail: cdzolnierek@texasnurses.org. Yet, legislators had difficulty appreciating the reality of violence in healthcare settings (D. Howard, personal communication, February 5, 2015). Why nurses need whistleblower protection. The ANA (2015) adopted its first formal code of ethics in 1950 to express the values and ideals for the nursing profession. American Nurses Association. Nurses and leaders must speak up when circumstances put the nurse and the patient at risk of harm. The Texas process has been criticized as cumbersome in emergency situations. The unit also has 18 general medical beds. As Director of Practice of the Texas Nurses Association, Ellen supports nurses’ efforts to influence policy through member engagement and assistance, collaboration, and communication. Nursing education programs first evolved outside of the general education system through hospital-based education for service models. As gaps in protection are identified, nurses work to address them through policy change. 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. Protections can be eroded through subsequent legislation or agency rules, and enforcement mechanisms may be weak or non-existent. This law allows up to $25,000 per occurrence to deter retaliatory behavior (Texas Senate Bill No. Retrieved from https://www.dshs.texas.gov/chs/cnws/Workplace-Violence-Study.aspx, Texas Legislature Online. Texas Patient Advocacy and Whistleblower Protections, (Reproduced with permission of Texas Nurses Association.). Texas Nursing Voice, 7(3): 1, 3-4. Short title. 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. Eligibility criteria and the Google Play logo are trademarks of Apple Inc. Google and. 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