Protect Your Patient, Protect Yourself: Know Your Nursing Practice Act Presenters: Judy Ho MSN, RN, ACNS- BC, CPHQ Geraldine Jones MS, RN-BC April 2010
Objectives List the primary types of Nursing Peer Review (NPR). Discuss how NPR can create and improve a better work environment for the nurses. Identify the minimum due process involved in a NPR.
Texas Board of Nursing Mission: to protect and promote the welfare of the people of Texas by ensuring that each person holding a license as a nurse in this state is competent to practice safely.
BON Rules & Regulations Rule 217. 11 Standards of Nursing Practice Rule 217. 12 Unprofessional Conduct Rule 219.19 Incident Based Peer Review and Whistle Blower Protections
Rule 217.12 Unprofessional Practice (1A) Carelessly failing, repeatedly failing, or exhibiting an inability to perform vocational, registered, or advanced practice nursing in conformity with the standards of minimum acceptable level of nursing practice set out in Rule 217.11.
Rule 217.12 Unprofessional Practice (1B) Carelessly or repeatedly failing to conform to generally accepted nursing standards in applicable practice settings;
Rule 217.12 Unprofessional Practice (1D) Delegating or assigning nursing functions or a prescribed health function when the delegation or assignment could reasonably be expected to result in unsafe or ineffective client care; Chapter 224: Delegation of Nursing Tasks by Registered Professional Nurses to Unlicensed Personnel for Clients with Acute Conditions or in Acute Care Environment
Rule 217.12 Unprofessional Practice (1F) Failing to supervise the performance of tasks by any individual working pursuant to the nurse s delegation or assignment
Rule 217.12 Unprofessional Practice (1E) Accepting the assignment of nursing functions or a prescribed health function when the acceptance of the assignment could be reasonably expected to result in unsafe or ineffective client care; Safe Harbor: Request to Determine Medical Reasonableness of a Physician Order
Rule 217.12 Unprofessional Practice (4) Careless or repetitive conduct that may endanger a clientʹs life, health, or safety. Actual injury to a client need not be established.
Rule 217.12 Unprofessional Practice (5) Inability to Practice Safelydemonstration of actual or potential inability to practice nursing with reasonable skill and safety to clients by reason of illness, use of alcohol, drugs, chemicals, or any other moodaltering substances, or as a result of any mental or physical condition;
Rule 217.12 Unprofessional Practice (6) A. Falsifying reports, client documentation, agency records or other documents (1C Improper management of client records) B. Failing to cooperate with a lawful investigation conducted by the board;
Rule 217.12 Unprofessional Practice (6) C. Causing or permitting physical, emotional or verbal abuse or injury or neglect to the client or the public, or failing to report same to the employer, appropriate legal authority and/or licensing board (6F: Threatening or violent behavior in the workplace);
Rule 217.12 Unprofessional Practice (6) D. Violating professional boundaries of the nurse/client relationship (physical, sexual, emotional or financial exploitation); E. Engaging in sexual conduct with a client, touching a client in a sexual manner, requesting or offering sexual favors, or language or behavior suggestive of the same;
Rule 217.12 Unprofessional Practice (8) Drug diversion
Rule 217.12 Unprofessional Practice (10) A. Use of any controlled substance or any drug, prescribed or unprescribed, or device or alcoholic beverages while on duty or on call and to the extent that such use may impair the nurseʹs ability to safely conduct to the public the practice authorized by the nurseʹs license;
Rule 217.12 Unprofessional Practice (10) B. Falsification of or making incorrect, inconsistent, or unintelligible entries in any agency, client, or other record pertaining to drugs or controlled substances; C. Failing to follow the policy and procedure in place for the wastage of medications at the facility where the nurse was employed or working at the time of the incident(s);
Rule 217.12 Unprofessional Practice (10) D. A positive drug screen for which there is no lawful prescription; or E. Obtaining or attempting to obtain or deliver medication(s) through means of misrepresentation, fraud, forgery, deception and/or subterfuge.
Rule 217.12 Unprofessional Practice (11) D. Failing to report violations of the Nursing Practice Act and/or the Boardʹs rules and regulations.
Rule 217.12 Unprofessional Practice (12) Leaving a nursing assignment, including a supervisory assignment, without notifying the appropriate personnel.
Conducts Subject to Reporting (Rule 217.19 Incident Based Nursing Peer Review & Whistleblower Protections) Violates the NPA or a Board Rule & contributed to the death or serious injury of a pt. Causes a person to suspect that the nurse s practice is impaired by chemical dependency or drug or alcohol abuse
Conducts Subject to Reporting (Rule 217.19 Incident Based Nursing Peer Review & Whistleblower Protections) Constitutes abuse, exploitation, fraud, or a violation of professional boundaries Indicates that the nurse lacks knowledge, skill, judgment, or consciousness (continued practice would pose a risk of harm)
What is a Minor Incident? Conduct by a nurse that does not indicate that the nurse s continued practice poses a risk of harm to a patient or another person. Minor error Minor violation
Peer Review What is it? The evaluation of: Nursing services The qualification of a nurse The quality of patient care rendered by a nurse The merits of a complaint concerning a nurse or nursing care A determination or recommendation regarding a complaint.
Nature of Nursing Peer Review Focused on obtaining relevant information 1. Fact finding 2. Analysis and study of events Occurs in a climate of collegial problem solving
What it is NOT!!! It is not part of the institution s corrective action process!!!
Nursing Peer Review Committee A committee established. for the purpose of conducting peer review.
Nursing Peer Review Committee Membership Must have nurses as three fourths of its members. Vocational nursing must include vocational nurses as members and may have only registered nurses and vocational nurses as voting members. Professional nursing must have registered nurses as two thirds of its members, and may have only registered nurses as voting members.
Nursing Peer Review Committee Membership Shall include to the extent feasible at least one nurse who has a working familiarity with the area of nursing practice in which the nurse being reviewed practices. Exclude from the committee, including attendance at the peer review hearing, any person or persons with administrative authority for personnel decisions directly relating to the nurse.
Who must have a peer review plan? 1. Vocational nurses if the person regularly employs, hires, or contracts for the services of 10 or more nurses 2. Professional nurses if the person regularly employs, hires, or contracts for the services of 10 or more nurses, at least five of whom are RN
What are the different types of NPR? Incident Based Peer Review includes minor incidents Safe Harbor Peer Review
Incident Based Peer Review Focuses on determining if a nurseʹs actions, be it a single event or multiple events (such as in reviewing up to five (5) minor incidents by the same nurse within a yearʹs period of time) should be reported to the Board, or if the nurseʹs conduct does not require reporting because the conduct constitutes a minor incident that can be remediated.
Minimum Due Process Rule 217.19 Incident Based NPR & Whistleblower Protections Nursing Peer Review Law TOC 303.002 Written polices and procedures at the conducting facility Level of participation of the nurse or nurse representative Confidentiality & safeguards to prevent impermissible disclosures
Minimum Due Process Rule 217.19 Incident Based NPR & Whistleblower Protections The incident based peer review committee will meet on a specified date not sooner than 21 calendar days & not more than 45 calendar days. Inform the nurse description on the event (s) to be evaluated. Provide the nurse the opportunity to review the documents (at least 15 days prior to the meeting).
Minimum Due Process Rule 217.19 Incident Based NPR & Whistleblower Protections Provide written notice to the nurse of the committeeʹs findings within 10 calendar fays of when the committee s review has been completed. Permit the nurse to file a rebuttal statement within 10 calendar days of the notice of the committee s findings.
NPR Committee s Responsibilities 1. Determine whether the Nurse undergoing the review engaged in reportable conduct or not. 2. Additional recommendation for the Nurse being reviewed is also included in the report to Board of Nursing (BON). 3. Report to the Chief Nursing Officer &/or Patient Safety Subcommittee on any related findings and recommendations that may have an impact on patient care.
Protect Your Patients! Know your Nursing Practice Act Always advocate for your patients safety practice within the standards & report unprofessional conduct
Protect Yourself!
SAFE HARBOR
SAFE HARBOR It s a State Law Texas Occupation Code 303.005, requires a person who regularly employs, hires or contracts for the services of at least ten (10) nurses to permit a nurse to request Peer Review
SAFE HARBOR RELATED TO NURSING WHA T? A process that a nurse can initiate WHE N? When a nurse is requested to engage on conduct that the she/he believes is in violation of his/her duty to a patient.
Duty To A Patient DUTY TO PATIENT Advocate for patient safety Avoid engaging in unprofessional conduct
DUTY TO A PATIENT PATIENT SAFETY IS THE NURSE S S HIGH is based on 217.11 ʺDuty to a patientʺ All nurses have a duty to maintain a safe environment for patients/clients and others for who the nurse is responsible. Unprofessional Conductʺ is based on 217.12 All nurses have a duty to maintain a safe environment for patients/clients and others for who the nurse is responsible.
DUTY TO A PATIENT VIOLATION OF DUTY TO A PA Means a requested conduct, (including administrative and MD decision) directly affecting a nurseʹs ability to comply with that duty, required by standards of practice.
Invoke Safe Harbor
Safe Harbor Relationship to Peer Review Standard 217.20 Safe Harbor Part of NPA Standard 217.11 Part of NPA Standard 217.12 Safe Harbor automatically initiates a formal investigation by the to NPR committee.
SAFE HARBOR A process that protects the nurse from retaliation When a nurse makes a good faith request for peer review That the nurse believes could result in a violation of NPA or Board Rules
SAFE HARBOR PROTECTIONS A nurse who in Good Faith request Safe Harbor: Good Faith action taken is supported by what is reasonable, factual and legal action doesn t reflect an intent to harm ( malice) May engage in the requested conduct pending NPR Is not reportable to BON if incident occurs during Safe Harbor time frame Employer retaliation is prohibited by law
BAD FAITH SAFE HARBOR NO! PROTECTION Knowingly and recklessly taking action not supported by a reasonable factual or legal basis Misrepresenting the facts surrounding the events Acting out of malice, animosity Acting from a conflict of interest
SAFE HARBOR PROCESS Invoke Safe Harbor prior to engagement in the conduct Immediately notify supervisor/manager Can be invoked at any time during the work period when the initial assignment changes Complete the Safe Harbor Form BON s Form Institution Form on the Source Signature requirement by staff and supervisor
SAFE HARBOR FORM Informative Process Must be completed by the nurse once Safe Harbor is invoked Includes 6 questions referring to: 1. Description of conduct requested 2. Who made the request 3. Name and title of person initiating the request 4. Description of practice setting, responsibilities, and resource 5. Why duty is violated 6. What changes are necessary
DUTY TO A PATIENT WHEN DOES DUTY TO PATIENT The nurse s duty is not defined by any single event such as clocking in or taking report. From a BON standpoint, the focus for disciplinary sanctions is on the relationship and responsibility of the nurse to the patient, not the employer. Patients are better off with the nurse than without the nurse in the vast majority of cases.
SAFE HARBOR MINIMUM DUE PROCESS The nurse shall be permitted to: Appear before the NPRC or the Informal Review Subcommittee (IRS) Ask questions and respond to questions of the NPRC Make a verbal and/or written statement to explain why he or she believes the requested conduct would have violated a RN s duty to a patient to a patient
SAFE HARBOR PROCESS NPR must be completed within 14 days of when the nurse invoked Safe Harbor Within 48 hrs of receiving the NPRC determination the nurse administrator must: a. Reviews the findings b. Notify the nurse c. Nurse protection ends if NPRC determines SH invoked in bad faith Reportable to BON. The nurse invoking Safe Harbor shall be given a copy of the committee determination
SAFE HARBOR
House and Senate Bills 81 st Regular Session of the Texas Legislature House Bill 3961 House Bill 4354 Senate Bill 476 Senate Bill 1415
Senate Bill 476 Protect the Nurses Nurses working in a hospital may refuse to work mandatory overtime & refusing to work overtime does not constitute patient abandonment. Requires hospitals to establish nurse staffing committees as standing committees of the hospital.
Senate Bill 476 Protect the Nurses Requires the governing body of a hospital to adopt, implement, and enforce a written official nurse services staffing policy that ensures that an adequate number and skill mix of nurses are available to meet the level of patient care needed.
Senate Bill 476 Protect the Nurses The nurse staffing committee is required to develop and recommend a nurse staffing plan to the hospital s governing body. Staffing plans should be used as a component of the nurse staffing budget & nurses are encouraged to provide input to the committee without fearing retaliation from their employer.
Questions?
References: Texas Board of Nurse Examiners, retrieved March 16, 2010 from, http://www.bon.state.tx.us/index.html Texas Legislature, retrieved March 16, 2010 from, www.capitol.state.tx.us/ Texas Board of Nurse Examiners, Position Statement, retrieved March 16, 2010 from, http://www.bon.state.tx.us/practice/p osition.html
What is my role? Why do I need to know to these stuff?