Week 9 :reflection- safe harbor

SAFE HABOUR COMPREHENSIVE REQUEST FOR NURSING SAFE HARBOR PEER REVIEW (SHPR) ONLY SECTION I (pages 3-6) MUST BECOMPLETED BY THE NURSE WHEN INITIALLY INVOKING SAFE HARBOR
A nurse’s request for Safe Harbor Must be in Writing, however, use of this form is not required for a nurse to invoke Safe Harbor. Any request for safe harbor, be it on this form or in any other written form or format, is subject to confidentiality requirements of NPA (TOC) §303. 006, §303. 007, §303. 0075, and Board Rule 217. 20.
Date: March 7, 2015Time: 7: 30 am Location: Texas U. S. A
I. NURSE’S REQUEST √□ Check if you completed a Quick Request for Safe Harbor Peer Review: date March 7, 2015 time 7: 30 am (*Skip to #3 and attach Quick Request Form copy to this Comprehensive Request)
(1) I (we) are invoking Safe Harbor and requesting a Safe Harbor peer review for the following requested conduct or assignment because I (we) believe in good faith that the conduct/assignment requested would potentially cause me (us) to violate my (our) duty to maintain a safe environment and provide safe nursing care to a patient(s) or client(s), or would constitute unprofessional conduct under BON statutes and rules, or criminal conduct.
I (we) request that a Safe Harbor Peer Review Committee (SHPRC) examine the facts and evidence of the situation described below to make a determination if compliance with the requested conduct or assignment is one that would cause me (us) to place patients at risk of harm, and thus violate our duty under standards §217. 11(1) (B) and (1) (T), or any other BON statutes or rules.
I (we) understand that unless the conduct or assignment requested would constitute:
A. Unprofessional conduct (Board Rule 217. 12)
B. A criminal act, or
C. An act that the nurse is unable to perform because he/she lacks the competency required to provide care that meets minimal standards of acceptable nursing practice that I (we) may accept the assignment and carry it out to the best of my(our) ability, without fear of risking licensure action by the Texas Board of Nursing.
The following nurse(s) hereby attest that we are invoking Safe Harbor:
Print Full Name and Type of License (LVN, RN) Nurse’s Signature
Jackie M. Hammocks FL RN License # 1017293, Current2011
[Attach additional names separately in writing if necessary]
(2) Name of person requesting the conduct or making the assignment (include licensure, job title or responsibility at the above date/time:
Dr. willfray Maccley (senior doctor at the taxes hospital)
(3) Describe your professional or reporting relationship to the supervisor/person requesting the conduct or assignment on this date/time:
Dr. will is always the manager at the hospital. The doctor values no suggestions from employees nor opinions away from his. Our association has not been a smooth one due to disagreements following my strict stand on the cord of conduct,
(4) Describe the conduct requested, or the assignment or directive received (if possible, attach photocopy if the request is in written form):
I currently work with a med-surgical unit in a medium-size hospital. The usual nurse-to-patient ratio is 1: 5, which I find heavy, but still I can manage the patient load. My shift is normally 7A to 7P. Today as I reported for my shift, there were several RNs calling in sick with the flu, and I was needed to take nine patients. When I questioned of additional staff from another unit, Dr. Will told me that the administration was attempting to get help for the unit but none was available at that time. That’s when I decided to take the assignment, but I insisted on the Safe Harbor
(5) Describe the practice setting (hospital, nursing home, home health, etc.), your responsibilities, and the resources available to you:
√□ Acute Care/Hospital (type of unit) 27 units
□ Long-Term Care/Nursing Home □ Nursing Instructor/Faculty
□ Home Health □ Community/Public Health □ Clinic (type) __________________________ □ other (explain below)
□ School Nurse ______________________
Position: √□ Staff Nurse □ Charge Nurse □ Nurse Manager/Supervisor □ other (explain below)
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
(6) Describe in detail, how the conduct requested would violate your duty to provide a safe environment and safe nursing care to a patient(s). If the conduct is patient specific, identify each affected patient by his/her initials and medical record number. It may be helpful, but is not required, to reference the standards in Board Rule 217. 11 you feel may be violated, and the patient safety concerns of the proposed conduct or assignment. Continue on separate paper and attach if necessary.
The concentration of Nurse to the patient is directly influenced by the quality of time spent on each patient. According to the norm of the hospital, each nurse nurses a maximum of 5 patients. This allows me to give quality serves to each client. But now the move to increase the ration to 1: 9 is like doubling the load without increment of time. The ratio reduces my quality service by half. The low quality service puts my career at a risk according to requirement under standards §217. 11(1) (B. 2008; Revised June 2013 5(Wong et al. 143)
Board Rule 217. 20(g) (2) requires both the nurse and supervisor to collaborate when the nurse refuses to engage in the requested conduct/assignment pending determination by the Safe Harbor Peer Review Committee (SHPRC). If the nurse refuses to collaborate with the supervisor or leaves the work setting without collaborating with the supervisor, the nurse may be acting in bad faith with regard to a Safe Harbor request and may be reportable to the board.
If the conduct requested would constitute unprofessional or criminal conduct, collaboration between the nurse and supervisor is not required, and however, any alternative assignment or conduct requested by the supervisor must not require the nurse to engage in unprofessional or criminal conduct.
(7) Please attach and list below any written materials (documents, forms, policies, diagrams, records, procedures, published literature or standards from nursing professional organizations, etc.) that you believe are pertinent to this request for Safe Harbor Peer Review. If some or all of the attachments are not readily available at the time this request is completed, they may be submitted to the Peer Review Committee and noted here at a later date/time prior to or at the time of the peer review hearing.
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
(8) If you think that the conduct or assignment could be carried out (without violation of your duty to a patient) if modified or if changes were made in the practice setting, describe the necessary modifications or changes. Continue on separate paper and attach if necessary.
The practice can be effected comfortably without any incident of bridge of conduct if necessary adjustments can be made. For instance, if the nurse number can be increased, the ration will reduce a bit thus making it easier to offer quality job. If overtime working can be permitted, enough time will be spent on each client, thus quality services can be delivered.
(9) Nurse’s Refusal to Accept Assignment under Board Rule 217. 20(g) (2)
I (we) believe in good faith that I (we) cannot accept the assignment requested because (Mark the ONE Applicable Box Below):
(A) □ I (we) lack the basic knowledge, skills, and abilities necessary to render the care assigned/conduct requested at a minimally competent level. I (we) believe that engaging in the assignment/conduct requested pending peer review committee determination would expose one or more patients to an unjustifiable risk of harm.
On_____________________(date/time), the patient safety concern raised by the nurse(s) initiating Safe Harbor Peer Review was jointly reviewed with ___________________________, who is the supervisor who made the assignment. 2008; Revised June 2013
Please provide a description of the resolution of the issue, or the rationale if unable to agree upon a safe assignment below (attach other pages as necessary):
Upon a disagreement on the necessary safety measures, the hospital should do referral of the patients to other hospitals around only to remain with a number that is manageable in respect to the number of nurses around (Wong et al. 123).
Name of Nurse(s) Initiating Date/time Name of Supervisor Date/time
(B) √□ I (we) believe that the assignment or conduct requested would constitute unprofessional conduct under the BON statutes and rules, or criminal conduct such as fraud, theft, falsification of records, patient abuse or exploitation, etc. See Nursing Practice Act Section 301. 452, Board Rule 217. 12, and applicable BON Disciplinary Sanction Policies http://www. bon. texas. gov/disciplinaryactions/dsp. html
(10) Nurse’s Decision to Sustain or Withdraw Request for Safe Harbor Peer Review
The situation described in either (A) or (B) above has been
□ satisfactorily resolved at this time and for this instance; or
□ remains unresolved at this time and for this instance.
I (we), being the nurse(s) who initiated this request for Safe Harbor, wish to:
□ Withdraw my (our) request for Safe Harbor and for a review by the peer review committee; or
√□ Sustain my (our) request for Safe Harbor and for a review by the Peer Review Committee (or physician if questioning the medical reasonableness of a physician order; see separate form) of the requested conduct, assignment or directive. 2008; Revised June 2013 7
II SUPERVISOR ACTIONS
(1) Acknowledgment of Receipt of Request for Safe Harbor
Comprehensive Request for Safe Harbor delivered to Supervisor by: ___________________________________ (Nurse requesting Safe Harbor)
Supervisor (name/signature) receiving Comprehensive Request for Safe Harbor form: _____________________________________________________________
Date: __________________Time: _______________Location: ________________
Supervisor’s Comments and Actions
□ See Quick Request Form or other document (describe below) of initial request for Safe Harbor:
Comments: _________________________________________________________
___________________________________________________________________
___________________________________________________________________
(2) On___________________(date/time) I delivered the Quick Request (if applicable) and Comprehensive Request for Safe Harbor along with any accompanying documents supplied by the nurse(s) invoking Safe Harbor to the Peer Review Chairperson, who is: _______________________________
(Name of Peer Review Chairperson)
____________________________________________
(Signature of supervisor/title) (Date/time)
III. REPORT OF PEER REVIEW COMMITTEE
(1) The Safe Harbor Peer Review Committee met to consider this request for Safe Harbor as follows:
Date: _____________________________ Time: ________________
Location: ______________________________________________
□ The nurse(s) requesting Safe Harbor were notified of the above meeting of the Safe Harbor Peer Review Committee (SHPRC) and given the opportunity to attend the meeting and offer testimony/answer questions in relation to this request for Safe Harbor. (Attach original green card returned w/ or w/o signature, and copy of envelope w/address mailed to and copy of dated notice of peer review letter).
(2) The Safe Harbor Peer Review Committee determined on the above date/time/location that the requested conduct, assignment, or directive:
□ Would have/Did violate the nurse’s duty to the patient(s); or
□ Would not have/Did not violate the nurse’s duty to the patient(s) 2008; Revised June 2013 8
(3) Rationale for Safe Harbor Peer Review Committee determination:
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
(4) On _______________________________ (date/time), this form was returned to the CNO/nurse administrator.
_______________________________________
Signature of SHPRC Chair or Representative
_______________________________________
Signature of CNO/Nurse Administrator
IV. REVIEW BY CNO/NURSE ADMINISTRATOR
(1) I have reviewed the SHPRC report and determined on __________________ (date/time) that the peer review committee:
□ correctly determined the nurse’s duty to the patient(s); or
□ did not correctly determine the nurse’s duty to the patient(s).
(2) Rationale: _____________________________________________________
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
(3) CNO/Nurse Administrator Action:
□ Withdraw or cancel requested assignment, directive, conduct effective ___________(date)____________(time).
□ Modified the request, assignment, or directive as follows:
___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________2008; Revised June 2013 9 _______________________________________________________
□ Made the following changes in the practice setting:
____________________________________________________________________________________________________________________________________________________________
□ Noticed the nurse(s) who invoked this request for Safe Harbor that the assignment, conduct, or directive stands as originally issued. I realize that no facility policy or directive from a CNO, nurse administrator, physician, or any other person can diminish or supersede a nurse’s duty to his/her patients [Board Rule 217. 11(1)(B) and Position Statement 15. 14 Duty of a Nurse In Any Setting].
In accordance with Board Rule 217. 20(j)(4)(B), if the CNO or nurse administrator disagrees with the decision of the SHPRC, the CNO or nurse administrator must document the rationale for disagreeing with the Peer Review Committee, and this documentation becomes a part of the permanent peer review record (see #2 above).
(4) On ____________________________ (date/time [must be no later than 48-hours after receiving determination from SHPRC]), this form and attachments were returned to:
□ The nurse(s) who initiated the request for SHPRC determination (original to nurse); and
□ The Peer Review Chair Person for maintenance with peer review committee records retention policy (permanent scanned electronic copy recommended) (copy of Safe Harbor request and attachments).
__________________________________________
Signature of CNO/Nurse Administrator Date
__________________________________________
Signature of Nurse(s) Initiating Safe Harbor Date
__________________________________________
Signature of SHPRC Chairperson Date 2008; Revised June 2013 10
Any request for Safe Harbor, be it on this form or in any other written form or format, is subject to confidentiality requirements of NPA (TOC) §303. 006, §303. 007, §303. 0075, and Board Rule 217. 20.
V. SAFE HARBOR PROTECTIONS TERMINATION DATE
The protections from Board of Nursing action on a nurse’s license under Texas Occupations Code, Section 301. 352 and Chapter 303 end for the nurse(s) making the request 48 hours after the peer review committee’s determination is received by the nurse(s) who initiated the Safe Harbor [Board Rule 217. 20(i)(3)].
In accordance with Board Rule 217. 20(e)(2), this does not affect the protections under the Nursing Peer Review Law section and the Nursing Practice Act section 301. 352 relating to a nurse’s protection from disciplinary action or discrimination for making a request for Safe Harbor Peer Review [303. 005(c)(1) and 303. 005(h)].
On __________________________ (date/time) I received the findings of the Peer Review Committee in writing as noted in Section IV of this form.
__________________________________________
Nurse(s) Who Initiated Peer Review Date
DO NOT FAX OR MAIL THIS FORM TO THE BON
(Please See Instructions Above & in Board Rule 217. 20).]
Texas Board of Nursing
SAFE HARBOR QUICK REQUEST FORM
{Remember to Complete Comprehensive Form/Information on Same Day}
Published May 2008 (rev. 9/08)
1. Nurse(s) Name(s) invoking Safe Harbor:
Jackie M. Hammocks
2. Date/Time of Request: March 7, 2015
3. Location of requested conduct/assignment Texas U. S. A
4. Name of person/supervisor (and title) making assignment or requesting the conduct:
Dr. willfray Maccley
5. Brief explanation of why invoking Safe Harbor (It may be helpful to review rules 217. 11 and
217. 12):
The work load is high than required. The load will compromise my capability to provide quality attention to the client. The failure to provide quality care to the patient will be a violation of standard requirement for my career. The failure to meet the requirements of my career , according to the Texas board of nurses, will put my career at risk (Melnyk et al. 123).
Signature(s) of Nurse(s) Invoking Safe Harbor:
____________________________________________________________________________
______________________________________________________________________
Signature of Supervisor/Person Making Assignment (Note: A supervisor’s refusal to sign this form does not render the nurse’s request for Safe Harbor invalid): ____________________
__________________________________________________________________________
2
The following portion of this form need be completed ONLY IF the nurse intends to refuse the requested assignment when invoking Safe Harbor.
6. I (we) believe in good faith that I (we) cannot accept the assignment requested because (Mark the
ONE Applicable Box Below): (A) G I (we) lack the basic knowledge, skills, and abilities necessary to competently perform the assignment. I (we) believe that engaging in the assignment/conduct requested pending peer review committee determination would expose one or more patients to an unjustifiable risk of harm. On_____________________ (date/time), the patient safety concern raised by the nurse(s) initiating safe harbor peer review was jointly reviewed with ___________________________, who is the supervisor who made the assignment. Please provide a description of the resolution of the issue, or the rationale if unable to agree upon a safe assignment below (attach other pages as necessary):
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
_______________________________ ___________________________
Name of Nurse(s) Initiating Date/time Name of Supervisor Date/time
(B) G I(we) believe that the assignment or conduct requested would constitute unprofessional conduct under the BON statutes and rules, or criminal conduct such as fraud, theft, falsification of records, patient abuse or exploitation, etc. See Nursing Practice Act Section 301. 452, BON Rule
217. 12, and applicable BON Disciplinary Sanction Policies http://www. bon. state. tx. us/disciplinaryaction/dsp. html.
Any request for safe harbor, be it on this form or in any other written form or format, is subject to confidentiality requirements of NPA (TOC) §303. 006, §303. 007, §303. 0075, and Rule 217. 20.
A mutual collaborative effort between the nurse(s) and supervisor making the assignment
is required by Rule 217. 20(g)(2) when the nurse refuses to engage in the requested conduct/assignment pending determination by the safe harbor peer review committee (SHPRC) because the nurse believes the assignment is not within the individual nurse’s scope of practice.
If the conduct requested would constitute unprofessional or criminal conduct, collaboration between the nurse and supervisor is not required, and however, any alternative assignment or conduct requested by the supervisor must not require the nurse to engage in unprofessional or criminal conduct.
REMEMBER TO COMPLETE COMPREHENSIVE REQUEST FOR SAFE HARBOR (SEE FORM)
REQUIRED PRIOR TO THE END OF, OR BEFORE LEAVING THE WORK ASSIGNMENT AREA.
Part 2: Reflection Questions
After you complete the two forms, answer these questions in the spaces provided.
1. How long did it take you to complete the Quick Form?
It took me 15 minutes to complete the Quick form.

2. How long did it take you to complete the Comprehensive Form?
It took me 25 minutes to complete the comprehensive form
3. Who else must complete portions of the form(s)?
i. The supervisor.
ii. The CNO/ Nurse supervisor
iii. The peer review committee
Works Cited
Melnyk, Bernadette M, and Ellen Fineout-Overholt. Evidence-based Practice in Nursing & Healthcare: A Guide to Best Practice. Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins, 2011. Print
Wong, Donna L, Marilyn J. Hockenberry, and David Wilson. Wongs Nursing Care of Infants and Children. St. Louis, Mo: Mosby/Elsevier, 2011. Print