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Four Options As To Taking Or Refusing A Nursing Assignment Despite

I think that PPs may be confusing Safe Harbor protections with governmental protections for Whistle Blowers. Safe Harbor is strictly limited to nursing practice issues & must be invoked at the onset of an assignment. The 'short form' must be followed with submission of the 'long form'. All SH incidents must be reviewed by the organization's Peer Review Committee. If Peer Review is not being administered properly, the Nurse Leader (DON, CNE, CNO, etc) is in violation of the Nurse Practice act... specifically, "unprofessional conduct" and her/his license could be in jeopardy. So, if any Tx nurse believes that these mandatory functions (Peer Review & Safe Harbor) are not being managed according to the law - this needs to be reported to the BON. This would take courage, because the 'reporter' would not be covered by any Whistleblower protections - which are specifically connected to compliance with Federal/State regulations, not BON.

Texas mandated Peer Review because we are the ONLY state with a legally defined Nurse-Patient duty (since 1984). As a result of that legislation, the BON's mandate for monitoring individual practice increased dramatically -- but of course, no additional resources were forthcoming to manage all the extra work. So, Tx created a process whereby the Peer Review process would begin at the local/employer level & only 'serious' issues would be taken on to the BON level. It works very well if an organization manages it correctly. I believe that Kansas also has mandated Peer Review now... so that makes 2 states.

I also want to point out that Safe Harbor protection is not just for bedside nurses. It can be applied whenever a nurse is asked to do something that s/he believes is contrary to out NPA. For instance, if a nurse educator is asked to train non-nurses to perform a nursing-only task, he could declare Safe Harbor so that the issue could be formally reviewed. All of us need to be very familiar with our NPAs - especially as they relate to our everyday work.

UNSAFE PATIENT ASSIGNMENT: When is it Abandonment, Insubordination or Negligence? What can you do to protect yourself and your patients?

ABANDONMENT: Once the healthcare worker receives a patient report, it is assumed that you have accepted the assignment unless you speak up and report any concerns to your unit manager. If you arrive after the shift report, it is assumed you have accepted the assignment. Thereafter to leave the patient care assignment would be considered ‘patient abandonment’.

INSUBORDINATION: Refusing an assignment that is reasonable with regards to your skill level, training, experience and licensure, could be seen as ‘Insubordination’ by your unit manager. Insubordination means not following work orders. In many work environments, insubordination can lead to disciplinary action such as counselling, suspension or even termination.

NEGLIGENCE: Accepting a patient assignment for which you are not qualified by training and experience could be considered negligence in some States. Negligence means failure to use the reasonable care of a prudent person in similar circumstances.

SCOPE of CARE/ Practice: ‘Scope of Care’ is usually defined by a professional body such as a Nurse Practice Act by a State Licensing Board. The level of licensure is one realm of scope of care, defining what skills may be performed lawfully by a RN, LPN, CNA, etc. Beyond the Scope of Care defined by State Boards, there are healthcare associations that define the scope for specialty practices such as for a Nurse Anesthetist, Dental Assistant or Labor & Delivery nurse.

EXPERIENCE: Some States have passed Laws and the federal government’s Senate has proposed a Bill ‘S-2353’, formerly called HR-1821, which requires healthcare facilities to make assignments that reflect the caregivers’ degree of experience. Experience means the time an individual has worked in a specific healthcare arena gaining valuable knowledge and skill specific to that arena. Laws are holding managers responsible for knowing the experience level of those workers that they assign.

Link to ANA’s summary of proposed legislation on healthcare assignments:

SPEAK UP: If you feel that the assignment is either outside of your scope of care or of your experience, then inform your unit manager. As a healthcare worker, you are responsible for knowing your own scope of care, your own experience, and for practicing within these. Being uncomfortable is not enough information for the manager. Indicate why you believe it is so. A shift of responsibility occurs whenever you report your concerns to the manager. The manager must act; a
decision must be made because you spoke up. Recognize that the manager has options you may not be aware of in terms of adjusting the assignment.

If you speak up and the manager does not make an assignment adjustment, and you continue to refuse the assignment, you may face the responsibility of insubordination or of patient abandonment.

What if you firmly and politely speak up that the assignment is beyond your scope of care and experience and you are still expected to perform? You have a conflict. It is time for conflict management skills.

CHAIN of COMMAND: Consider if there is anyone else within the management line with whom you can register your concern. Is there a Unit Head Nurse? Is there a Hospital Supervisor? Is there a Human Resource
or Staffing Manager to whom you can speak? If no one else is available, then you can email yourself a message that you raised a concern and no change was made in the assignment. This will document your actions and that you attempted to address your concern in a reasonable manner, something a “prudent person would do”. It is unwise to complain to peers, since they have no authority to improve the situation. See also the ADO form described below.

ADO PROCESS: Washington State even has a form that can be completed called: “Assignment despite objection” (ADO). Completing the form is considered a “good faith effort” and adds responsibility to the manager should anything injurious occur. Even if your State does not have a similar form, this form can be used as a guide for documentation. There is no requirement for the manager-supervisor to sign the form. If they decline to do so, print the name and title of the person to whom you submitted your report. ADO form:

TRANSFER of CARE: Avoid patient abandonment. If the assignment has begun, you have spoken up to someone in authority, not just complained to a peer, and you find the care needs are beyond your skill and experience, then write down your report. Keep a dated copy for yourself. Then transfer the care to the nurse manager ensuring that they receive the report. Document in the patient record that you have transferred the care and document to whom the report was given. It is not abandonment if the care is properly transferred.

Several State Nurses Associations have written position papers about risky assignments and indicated their recommendations. This is the link to the Washington position paper:

CONTACT EHP: Inappropriate assignments in healthcare are not new occurrences. At EHP there will always be someone available to register your concern and do what is in our power to improve the situation. As soon as possible – phone call or text EHP. There is a strong chance that EHP will be able to advocate for you.

In summary if you receive a risky assignment, your options include:
1) Call or text EHP.
2) Speak up to the unit manager and voice your concerns.
3) If no change occurs, complete a form like the Washington ADO form. Keep a copy and give a copy to the manager.
4) If the patient care is seriously beyond your skill, transfer care by written report to the manager. Keep a copy of the report. Do not abandon the patient.
5) Let EHP know what action you took.

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