NURS 4223N Trends Blueprint Exam 2

NURS 4223N Trends Blueprint Exam 2 60 Questions in 80 Minutes (112 minutes of Video) 1. Safe Harbor (Week 3) 9 questions Readings: □ Safe Harbor: Rule 217.20: Safe Harbor Peer Review for Nurses and Whistleblower Protections (a) Definitions. (1) Assignment--Designated responsibility for the provision or supervision of nursing care for a defined period of time in a defined work setting. This includes but is not limited to the specified functions, duties, practitioner orders, supervisory directives, and amount of work designated as the individual nurse's responsibility. Changes in the nurse's assignment may occur at any time during the work period. (2) Bad Faith--Knowingly or recklessly taking action not supported by a reasonable factual or legal basis. The term includes misrepresenting the facts surrounding the events under review, acting out of malice or personal animosity towards the nurse, acting from a conflict of interest, or knowingly or recklessly denying a nurse due process. (3) Chief Nursing Officer (CNO)--The registered nurse, by any title, who is administratively responsible for the nursing services at a facility, association, school, agency, or any other setting that utilizes the services of nurses. (4) Conduct Subject to Reporting defined by Texas Occupations Code (TOC) §301.401 of the Nursing Practice Act as conduct by a nurse that: (A) violates the Nursing Practice Act (NPA) or a Board rule and contributed to the death or serious injury of a patient; (B) causes a person to suspect that the nurse's practice is impaired by chemical dependency or drug or alcohol abuse; (C) constitutes abuse, exploitation, fraud, or a violation of professional boundaries; or (D) indicates that the nurse lacks knowledge, skill, judgment, or conscientiousness to such an extent that the nurse's continued practice of nursing could reasonably be expected to pose a risk of harm to a patient or another person, regardless of whether the conduct consists of a single incident or a pattern of behavior. (5) Duty to a patient--A nurse's duty is to always advocate for patient safety, including any nursing action necessary to comply with the standards of nursing practice (§217.11 of this title) and to avoid engaging in unprofessional conduct (§217.12 of this title). This includes administrative decisions directly affecting a nurse's ability to comply with that duty. (6) Good Faith--Taking action supported by a reasonable factual or legal basis. Good faith precludes misrepresenting the facts surrounding the events under review, acting out of malice or personal animosity, acting from a conflict of interest, or knowingly or recklessly denying a nurse due process. (7) Incident-Based Peer Review--Incident-based peer review focuses on determining if a nurse's 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 year's period of time) should be reported to the Board, or if the nurse's conduct does not require reporting because the conduct constitutes a minor incident that can be remediated. The review includes whether external factors beyond the nurse's control may have contributed to any deficiency in care by the nurse, and to report such findings to a patient safety committee as applicable. (8) Malice--Acting with a specific intent to do substantial injury or harm to another. (9) 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 as described in §217.16 of this title. (10) Nurse Administrator--Chief Nursing Officer (CNO) or the CNO's designee. (11) Nursing Peer Review Law (NPR law)--Chapter 303 of the TOC. Nurses involved in nursing peer review must comply with the NPR Law. (12) Nursing Practice Act (NPA)--Chapter 301 of the TOC. Nurses must comply with the NPA. (13) Patient Safety Committee--Any committee established by an association, school, agency, health care facility, or other organization to address issues relating to patient safety including: (A) the entity's medical staff composed of individuals licensed under Subtitle B (Medical Practice Act, TOC §151.001, et seq); (B) a medical committee under Subchapter D, Chapter 161 of the Health and Safety Code (§§161.031 - 161.033); or (C) a multi-disciplinary committee, including nursing representation, or any committee established by the same entity to promote best practices and patient safety. (14) Peer Review--Defined by TOC §303.001(5) (NPR Law) as the evaluation of nursing services, the qualifications of a nurse, the quality of patient care rendered by a nurse, the merits of a complaint concerning a nurse or nursing care, and a determination or recommendation regarding a complaint. The term also includes the provision of information, advice, and assistance to nurses and other persons relating to the rights and obligations of and protections for nurses who raise care concerns, report under Chapter 301, request peer review, and the resolution of workplace and practice questions relating to nursing and patient care. The peer review process is one of fact finding, analysis and study of events by nurses in a climate of collegial problem solving focused on obtaining all relevant information about an event. Peer review conducted by any entity must comply with NPR Law and with applicable Board rules related to incident-based or safe harbor peer review. (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 faith request for peer review of an assignment or conduct the nurse is requested to perform and that the nurse believes could result in a violation of the NPA or Board rules. Safe Harbor must be invoked prior to engaging in the conduct or assignment for which peer review is requested, and may be invoked at anytime during the work period when the initial assignment changes. (16) Texas Occupations Code (TOC)--One of the topical subdivisions or "codes" into which the Texas Statutes or laws are organized. The TOC contains the statutes governing occupations and professions including the health professions. Both the NPA and NPR Law are located within these statutes. The TOC can be changed only by the Texas Legislature. (17) Whistleblower Protections--Protections available to a nurse that prohibit retaliatory action by an employer or other entity because the nurse: (A) made a good faith request for Safe Harbor Nursing Peer Review under TOC §303.005(c) and this section; or (B) refused to engage in an act or omission relating to patient care that would constitute a violation of the NPA or Board rules as permitted by TOC §301.352 (NPA) (Protection for Refusal to Engage in Certain Conduct). A nurse invoking Safe Harbor under this section must comply with subsection (g) of this section if the nurse refuses to engage in the conduct or assignment; or (C) made a lawful report of unsafe practitioners, or unsafe patient care practices or conditions, in accordance with TOC §301.4025 (report of unsafe practices of non-nurse entities) and §217.19(j)(2) of this title. (b) Purpose. The purpose of this rule is to: (1) define the process for invoking Safe Harbor; (2) define minimum due process to which a nurse is entitled under safe harbor peer review; (3) provide guidance to facilities, agencies, employers of nurses, or anyone who utilizes the services of nurses in the development and application of peer review plans; (4) assure that nurses have knowledge of the plan as well as their right to invoke Safe Harbor; and (5) provide guidance to the peer review committee in making its determination of the nurse's duty to the patient. (c) Applicability of Safe Harbor Nursing Peer Review. (1) TOC §303.0015 (NPR Law) requires a person who regularly employs, hires or contracts for the services of ten (10) or more nurses (for peer review of an RN, at least 5 of the 10 must be RNs) to permit a nurse to request Safe Harbor Peer Review when the nurse is requested or assigned to engage in conduct that the nurse believes is in violation of his/her duty to a patient. (2) Any person or entity that conducts Safe Harbor Nursing Peer Review is required to comply with the requirements of this rule. (d) Invoking Safe Harbor. (1) Safe Harbor must be invoked prior to engaging in the conduct or assignment and at any of the following times: (A) when the conduct is requested or assignment made; (B) when changes occur in the request or assignment that so modify the level of nursing care or supervision required compared to what was originally requested or assigned that a nurse believes in good faith that patient harm may result; or (C) when the nurse refuses to engage in the requested conduct or assignment. (2) The nurse must notify the supervisor requesting the conduct or assignment in writing that the nurse is invoking Safe Harbor. The content of this notification must meet the requirements for a Quick Request Form described in paragraph (3) of this subsection. A detailed written account of the Safe Harbor request that meets the minimum requirements for the Comprehensive Written Request described in paragraph (4) of this subsection must be completed before leaving the work setting at the end of the work period. (3) Quick Request Form. (A) A nurse wishing to invoke Safe Harbor must make an initial request in writing that at a minimum includes the following: (i) the nurse(s) name making the safe harbor request and his/her signature(s); (ii) the date and time of the request; (iii) the location of where the conduct or assignment is to be completed; (iv) the name of the person requesting the conduct or making the assignment; and (v) a brief explanation of why safe harbor is being requested. (B) The BON Safe Harbor Quick Request Form may be used to invoke the initial request for Safe Harbor, but use of the form is not required. The initial written request may be in any written format provided the above minimum information is provided. (4) Comprehensive Written Request for Safe Harbor Peer Review. (A) A nurse who invokes Safe Harbor must supplement the initial written request under paragraph (3)(A) of this subsection by submitting a comprehensive request in writing before leaving the work setting at the end of the work period. This comprehensive written request must include a minimum of the following information: (i) the conduct assigned or requested, including the name and title of the person making the assignment or request; (ii) a description of the practice setting, e.g., the nurse's responsibilities, resources available, extenuating or contributing circumstances impacting the situation; (iii) a detailed description of how the requested conduct or assignment would have violated the nurse's duty to a patient or any other provision of the NPA and Board Rules. If possible, reference the specific standard (§217.11 of this title) or other section of the NPA and/or Board rules the nurse believes would have been violated. (iv) If applicable, the rationale for the nurse's not engaging in the requested conduct or assignment awaiting the nursing peer review committee's determination as to the nurse's duty. The rationale should refer to one of the justifications described in subsection (g)(2) of this section for not engaging in the conduct or assignment awaiting a peer review determination. (v) any other copies of pertinent documentation available at the time. Additional documents may be submitted to the committee when available at a later time; and (vi) the nurse's name, title, and relationship to the supervisor making the assignment or request. (B) The BON Comprehensive Request for Safe Harbor Form may be used when submitting the detailed request for Safe Harbor, but use of the form is not required. The comprehensive written request may be in any written format provided the above minimum information is included. (5) The nurse invoking Safe Harbor is responsible for keeping a copy of the request for Safe Harbor. (6) A nurse may invoke Safe Harbor to question the medical reasonableness of a physician's order in accordance with TOC §303.005(e) (NPR Law). In this situation, the medical staff or medical director shall determine whether the order was reasonable. (e) Safe Harbor Protections. (1) To activate protections outlined in TOC §303.005(c) and paragraph (2) of this subsection, the nurse shall: (A) invoke Safe Harbor in good faith; (B) notify the supervisor in writing that he/she intends to invoke Safe Harbor in accordance with subsection (d) of this section. This must be done prior to engaging in the conduct or assignment for which safe harbor is requested and at any of the following times: (i) when the conduct is requested or assignment made; (ii) when changes occur in the request or assignment that so modify the level of nursing care or supervision required compared to what was originally requested or assigned that a nurse believes in good faith that patient harm may result; or (iii) when the nurse refuses to engage in the requested conduct or assignment. (2) TOC §303.005(c) and (h) (NPR Law) and §301.352 provide the following protections: (A) A nurse may not be suspended, terminated, or otherwise disciplined, retaliated, or discriminated against for requesting Safe Harbor in good faith. (B) A nurse or other person may not be suspended, terminated, or otherwise disciplined, retaliated, or discriminated against for advising a nurse in good faith of the nurse's right to request a determination, or of the procedures for requesting a determination. (C) A nurse is not subject to being reported to the Board and may not be disciplined by the Board for engaging in the conduct awaiting the determination of the peer review committee as permitted by subsection (g) of this section. A nurse's protections from disciplinary action by the Board for engaging in the conduct or assignment awaiting peer review determination remain in place for 48 hours after the nurse is advised of the peer review committee's determination. This time limitation does not affect the nurse's protections from retaliation by the facility, agency, entity or employer under TOC §303.005(h) (NPR Law) for requesting Safe Harbor. (3) If retaliation occurs, TOC §301.413 (NPA) provides a nurse the right to file civil suit to recover damages. The nurse may also file a complaint with the appropriate regulatory agency that licenses or regulates the nurse's practice setting. The BON does not have regulatory authority over practice settings or civil liability. (4) Safe Harbor protections do not apply to any civil action for patient injury that may result from the nurse's practice. (f) Exclusions to Safe Harbor Protections. (1) A nurse's protections from disciplinary action by the Board under subsection (e)(2) of this section do not apply to: (A) the nurse who invokes Safe Harbor in bad faith; (B) conduct the nurse engages in prior to the request for Safe Harbor; or (C) conduct unrelated to the reason for which the nurse requested Safe Harbor. (2) If the peer review committee determines that a nurse has engaged in conduct subject to reporting that is not related to the request for Safe Harbor, the committee must comply with the requirements of §217.19 of this title. (g) Nurse's Right to Refuse to Engage in Certain Conduct Pending Nursing Safe Harbor Peer Review Determination. (1) A nurse invoking safe harbor may engage in the requested conduct or assignment while awaiting peer review determination unless the conduct or assignment is one in which: (A) the nurse lacks the basic knowledge, skills, and abilities that would be necessary to render the care or engage in the conduct requested or assigned at a minimally competent level such that engaging in the requested conduct or assignment would expose one or more patients to an unjustifiable risk of harm; or (B) the requested conduct or assignment would constitute unprofessional conduct and/or criminal conduct such as fraud, theft, patient abuse, exploitation, or falsification. (2) If a nurse refuses to engage in the conduct or assignment because it is beyond the nurse's scope as described under paragraph (1)(A) of this subsection: (A) the nurse and supervisor must collaborate in an attempt to identify an acceptable assignment that is within the nurse's scope and enhances the delivery of safe patient care; and (B) the results of this collaborative effort must be documented in writing and maintained in peer review records by the chair of the peer review committee. (h) Minimum Due Process. (1) A person or entity required by TOC §303.005(i) to provide nursing peer review shall adopt and implement a policy to inform nurses of their right to request a nursing peer review committee determination (Safe Harbor Nursing Peer Review) and the procedure for making a request. (2) In order to meet the minimum due process required by TOC Chapter 303, the nursing peer review committee shall: (A) comply with the membership and voting requirements as set forth in TOC §303.003; (B) exclude from the committee membership, any persons or person with administrative authority for personnel decisions directly affecting the nurse; (C) limit attendance at the Safe Harbor Nursing Peer Review hearing by a CNO, nurse administrator, or other individual with administrative authority over the nurse, including the individual who requested the conduct or made the assignment, to appearing before the safe harbor peer review committee to speak as a fact witness; and (D) Permit the nurse requesting safe harbor to: (i) appear before the committee; (ii) ask questions and respond to questions of the committee; and (iii) make a verbal and/or written statement to explain why he or she believes the requested conduct or assignment would have violated a nurse's duty to a patient. (i) Safe Harbor Timelines. (1) The Safe Harbor Nursing Peer Review committee shall complete its review and notify the CNO or nurse administrator within 14 calendar days of when the nurse requested Safe Harbor. (2) Within 48 hours of receiving the committee's determination, the CNO or nurse administrator shall review these findings and notify the nurse requesting safe harbor of both the committee's determination and whether the administrator believes in good faith that the committee's findings are correct or incorrect. (3) The nurse's protection from disciplinary action by the Board for engaging in the conduct or assignment awaiting peer review determination expires 48 hours after the nurse is advised of the peer review committee's determination. The expiration of this protection does not affect the nurse's protections from retaliation by the facility, agency, entity or employer under TOC §303.005(h) for requesting Safe Harbor. (j) General Provisions. (1) The Chief Nursing Officer (CNO) or nurse administrator of a facility, association, school, agency, or of any other setting that utilizes the services of nurses is responsible for knowing the requirements of this Rule and for taking reasonable steps to assure that peer review is implemented and conducted in compliance with the NPA and the NPR law. (2) Safe Harbor Nursing Peer Review must be conducted in good faith. A nurse who knowingly participates in nursing peer review in bad faith is subject to disciplinary action by the Board. (3) The peer review committee and participants shall comply with the confidentiality requirement of TOC §303.006 and §303.007 relating to confidentiality and limited disclosure of peer review information. (4) If a nurse requests a Safe Harbor Peer Review determination under TOC §303.005(b) and refuses to engage in the requested conduct or assignment pending the safe harbor peer review, the determinations of the committee are not binding if the CNO or nurse administrator believes in good faith that the committee has incorrectly determined a nurse's duty. (A) In accordance with TOC §303.005(d), the determination of the safe harbor peer review committee shall be considered in any decision by the nurse's employer to discipline the nurse for the refusal to engage in the requested conduct. (B) If the CNO or nurse administrator in good faith disagrees with the committee's determination, the rationale for disagreeing must be recorded and retained with the peer review records. (C) If the CNO or nurse administrator believes the peer review was conducted in bad faith, she/he has a duty to report the nurses involved under TOC §301.402 (NPA) and §217.11(1)(K) of this title. (D) This section does not affect the protections under TOC §303.005(c)(1) and §301.352 relating to a nurse's protection from disciplinary action or discrimination for making a request for Safe Harbor Peer Review. (k) Use of Informal Work Group In Safe Harbor Nursing Peer Review. A facility may choose to initiate an informal review process utilizing a workgroup of the nursing peer review committee provided that the final determination of the nurse's duty complies with the time lines set out in this rule and there are written policies for the informal workgroup that require: (1) the nurse to: (A) be informed how the informal workgroup will function and that the nurse does not waive any right to peer review by accepting or rejecting the use of an informal workgroup; and (B) consent, in writing, to the use of an informal workgroup; (2) the informal workgroup to comply with the membership and voting requirements of subsection (h) of this section; (3) the nurse to be provided the opportunity to meet with the informal workgroup; (4) the nurse to have the right to reject any decision of the informal workgroup and have the entire committee determine if the requested conduct or assignment violates the nurse's duty to the patient(s), in which event members of the informal workgroup shall not participate in that determination; (5) ratification by the safe harbor peer review committee chair person of any decision made by the informal workgroup. If the chair person disagrees with a determination of the informal workgroup, the chair person shall convene the full peer review committee to review the conduct in question; and (6) the peer review chair person communicate any decision of the informal work group to the CNO or nurse administrator. (l) Reporting Conduct of other Practitioners or Entities; Whistleblower Protections. (1) This subsection does not expand the authority of any safe harbor peer review committee or the Board to make determinations outside the practice of nursing. (2) In a written, signed report to the appropriate licensing Board or accrediting body, and in accordance with TOC §301.4025, a nurse may report a licensed health care practitioner, agency, or facility that the nurse has reasonable cause to believe has exposed a patient to substantial risk of harm as a result of failing to provide patient care that conforms to: (A) minimum standards of acceptable and prevailing professional practice, for a report made regarding a practitioner; or (B) statutory, regulatory, or accreditation standards, for a report made regarding an agency or facility. (3) A nurse may report to the nurse's employer or another entity at which the nurse is authorized to practice any situation that the nurse has reasonable cause to believe exposes a patient to substantial risk of harm as a result of a failure to provide patient care that conforms to minimum standards of acceptable and prevailing professional practice or to statutory, regulatory, or accreditation standards. For purposes of this subsection, an employer or entity includes an employee or agent of the employer or entity. (4) A person may not suspend or terminate the employment of, or otherwise discipline, retaliate, or discriminate against, a person who reports, in good faith, under this section or advises a nurse of the nurse's rights and obligations under this section. A violation of this subsection is subject to TOC §301.413 that provides a nurse the right to file civil suit to recover damages. The nurse may also file a complaint with the regulatory agency that licenses or regulates the nurse's practice setting. The BON does not have regulatory authority over practice settings or civil liability. □ Safe Harbor Forms and Explanation of Safe Harbor With the revisions to the Nursing Peer Review statutes (effective 9/1/2007) and nursing peer review rules (effective 5/11/2008), new forms have been developed 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 the nurse's scope of practice, or engage in unprofessional or illegal conduct. The Texas Board of Nursing (BON) provides the following three forms which may be used as part of the process (please do not send these Safe Harbor forms to the BON): • Quick Request for Safe Harbor Form The Quick Request for Safe Harbor is an abbreviated form to allow a nurse to quickly jot down the key information necessary to invoke Safe Harbor in writing as required by Rule 217.20 at the time the nurse is asked to accept what he/she believes to be an unsafe assignment. Use of the form is not required, but is provided to make safe harbor an easier process for the nurse. • Comprehensive Request for Safe Harbor Form The Comprehensive Request for Safe Harbor Form is a sample form that may be used to document the more in-depth information that the nurse must commit to writing before leaving the work setting at the end of the work period. The nurse may still supply supporting documents at a later time, however the details of the events surrounding the request must be recorded prior to the nurse leaving the premises. The comprehensive form also includes a fill-in-the- blank format that the peer review committee and CNO or nurse administrator can utilize to document the safe harbor peer review process. Again, this form is not mandatory, but is offered a guide to the process. An entity required to have a peer review plan must have policies and procedures that encompass other aspects both within and beyond the statutes and rules of peer review. In other words, it is not sufficient to use the BON Safe Harbor forms in place of official policies and procedures on nursing peer review. • Safe Harbor Request to Question the Medical Reasonableness of a Physician's Order Form. The third form, Safe Harbor Request to Question the Medical Reasonableness of a Physician's Order, is for those occasions when the reason for the nurse's need to invoke Safe Harbor is related to the actions or orders of a physician. In this case, the nurse may not need to use either the Quick or the Comprehensive request forms, since it will be an individual physician who will make a determination, rather than a nursing peer review committee. In other words, to question the medical reasonableness of a physicians order, a nurse will likely only need to use this third form by itself. A facility or other entity establishing a nursing peer review plan may establish it's own forms and procedures that comply with the peer review statutes and Rule 217.20 Safe Harbor Peer Review. You may wish to review Frequently Asked Questions Peer Review, or BON Nursing Peer Review FAQ PDF in addition to the above BON Safe Harbor Forms. A Reference Table to help locate rules and statutes relating to peer review topics is also available on the BON's web site under Nursing Peer Review. Videos: □ Safe Harbor (w/ accompanying transcript) (13 minutes) Slide 1: Safe Harbor • Texas Occupations Code (TOC) – 301.352 (NPA) – 303.005 (PR) • Form located at • Win-Win process Our next topic is Safe Harbor. I expect that you have read the 2 statutes indicated on this slide, as well as reviewed the 3 Safe Harbor forms that can be found on the BON website. I want to emphasize a few aspects of Safe Harbor for your understanding. Safe Harbor came about as a result of the legislators gaining understanding of the difficult situations in which nurses find themselves, especially with staffing shortages. I am perplexed as to how a piece of legislation that could be so positive for nursing in Texas has been so misunderstood. Safe Harbor is a win-win ---win for the nurse, win for the employer--- process. Let’s review why this is so Slide 2: Nurses’ Options 1. Accept 2. Refuse 3. Refuse, and request PR – if disciplined [301.352] (1995 Legislature) 4. File Safe Harbor and accept [303.005] (1997 Legislature) It is important to remember that you now have 4 choices as a Registered Nurse when given an assignment. You can accept or you can refuse the assignment. Nurses have always had these 2 choices. But in 1995 and in 1997, through statutory changes to the Nursing Practice Act and Peer Review, you were provided with 2 additional choices. Even though you have the choice of invoking Safe Harbor now, there are times when you still must Refuse an assignment in consideration of patient safety. Your 4 choices, therefore, are as follows: 1. Accept the assignment- and if anything untoward occurs with the patient, you may find yourself in a malpractice suit as well as under license investigation 2. Refuse the assignment- and face possible employer disciplinary action or retaliation 3. In 1995, the legislators gave you a 3rd option- 301.352, entitled Protection for Refusal to Engage in Certain Conduct. With this option, you can refuse the assignment and IF DISCIPLINED and ONLY, if disciplined, ask the Peer review Committee to meet and determine if you were right to have refused. IN other words, the assignment was so unsafe, that accepting it would have been a violation of the Texas Nursing Practice Act. If the PRC agrees with you- you were right to have refused, then you must give your employer the opportunity to “un-do” the actions that were taken against you. If the employer does not “un-do” the discipline or retaliation, then you have a cause of action to proceed against them in a court of law. However, if the PRC does not agree with you, then the discipline- retaliation stands. 4. In 1997, the legislators gave you a 4th option in 303.005 Safe Harbor. With this option, you TAKE the assignment. Let me repeat that- with Safe Harbor you stay and take the assignment you are being given. But, you file Safe Harbor to protect your license. Win for the employer-you stay and take the assignment. Win for the nurse- your license is protected if something untoward happens to the patient while you are in that Safe Harbor, which you know can be for up to 16 days. By filing Safe Harbor, you are asking the PRC to meet and determine are you right? Is this assignment so unsafe that your taking it is a violation of the Nursing practice Act and therefore, reportable conduct? If the PRC agrees with you, then you should stop taking it. If the PRC does not agree with you, then you have your answer- you should take the assignment. But the Board always emphasizes that the ultimate decision to accept or refuse an assignment is yours- you have the duty to the patient and it is YOUR license 24 hours/day, 7 days/week. I have heard Board staff say many times in Informal Hearings, that it is better to have lost a job, than to have lost-or placed in jeopardy- your license. Both the Nursing Practice Act and the Hospital Staffing Rules state that a nurse should not be retaliated upon for filing Safe Harbor. Therefore, if any one has threatened you with employment retaliation or if you have threatened anyone who states that he or she wants to file Safe Harbor, I consider that to be a violation of both statute and Rules. We truly need to work together on these issues that lead to the filing of Safe Harbor. The most classic reasons for filing Safe Harbor? Too high Nurse-Patient Ratio and Inappropriate Float. We have had Safe Harbor in Texas since 1997 and I believe it is just beginning to be used and understood in the workplace. Slide 3: Safe Harbor is Nurse’s Decision • Protects license • Does not protect the RN/LVN in civil liability action for bad patient outcome (malpractice) Remember that the decision to file Safe Harbor is yours, the nurses. If you file Safe Harbor, your license will be protected. But the statute offers no protection for malpractice. In fact, a Safe Harbor form, like an Incident Report, is not discoverable- not admissible- in a malpractice case Slide 4: Safe Harbor Forms • Request by the RN/LVN • Short Form • Long Form • Medical Reasonableness Beginning in 2008, 3 forms are available to the nurse invoking Safe Harbor. The short form to be completed before taking the assignment, the long form to be completed before the end of your shift and the Medical Reasonableness/Physician Order form to be completed if there is a question as to the action or order of a physician. In the past there was just one form which was 8 to 9 pages long. Nurses labored under the misconception that they had to complete the entire form (rather than just a few sections on the 1st 2 pages), so the positive aspect of now having 3 forms is that it helps to dispel that misconception Slide 5: When to Invoke Protections • Safe Harbor defense before the BON • Available to LVNs since February 1, 2004 (One Practice Act) • Example case – L & D nurse was asked to work in cardiac unit If you are under investigation and you make the argument in your defense for example .. “I did miss that antibiotic order (to the detriment of the patient), but I was working charge and had patients of my own and then got a critical admit in the 8th hour of my 12 hour shift”. You likely will be asked, “Why didn’t you file Safe Harbor?” The Board, the Board staff, legislators and other nurses on special committees worked long and hard to provide you with a license protection mechanism. If you choose not to use it- and it IS your choice, then you will be the one to deal with the consequences. What does the Board want? Safe Nurses. Nurses who can Critically Think in situations. Take the example of an assignment that is too high a Nurse- Patient Ratio. By filing Safe Harbor, you are saying, “I AM a critically thinking nurse. I recognize this assignment as so unsafe that by taking it I may not be able to meet my duty to the patient—but if I do not take it, the patients will be even worse off.” I want to relate to you a case in which I was involved and which, I hope, will shed further light on the 4 options that you have. I was involved with this case as a consulting attorney, due to my knowledge of the Nursing Practice Act and Board Rules. An employment law attorney represented the Nurse. The facts of the case were as follows: The Nurse was an L&D Nurse who had done nothing but L&D for about 12 years. She came to work one morning and was told to float to the cardiac step- down unit. She stated that she could not take patients, that she felt the assignment violated the Practice Act and that it wasn’t safe for the patients- she was uneducated as to current cardiac drugs, treatments, reading cardiac monitoring strips and, she added “I don’t know the doctors up on that unit and won’t know how to recognize their writing” {Roll Eyes} She did volunteer to go to the cardiac unit and help out similar to an aid- take vitals, make beds, pass trays. She went to the unit and was in the second room and had just gotten the patient’s vital signs when the Charge Nurse entered the room and asked her for the vital signs. When she told the Charge Nurse the Charge Nurse stormed out of the room, yelling “Why didn’t you tell me? He has an order if his vitals change!!!” Now, the L&D Nurse was even anxious about functioning as an aid. Shortly thereafter, the Charge Nurse returned and said “The agency nurse didn’t show- you have to take patients” The L&D Nurse refused “No, I won’t” “Yes, you will” “No, I won’t” So the Charge told her to go back to L&D and wait to be contacted. The L&D Nurse returned to L&D. She went to the nurses’ lounge. She was crying- it had been an unpleasant confrontation. She quickly received a call from the House Supervisor, with the same back and forth- Yes, No, Yes, No. And the House Supervisor then told her to clock out and go home. She went home and awaited a call from her L&D unit manager, who had not arrived at work yet, when all the confrontation was occurring The Unit Manager called her at home later in the morning and asked for her side of the story. After telling the Unit manager the events of the morning- which was a Monday morning- The Unit Manager told her that she was suspended temporarily and that she was to report to the hospital on Thursday- 3 days later Now the L&D Nurse was really concerned. She called the Board and asked to speak with a Nurse Consultant. She told the Nurse Consultant about the events of the day. The Nurse Consultant had to go to a meeting and asked the L&D Nurse to send her an email. The L&D Nurse did, and the Nurse Consultant emailed back to the L&D Nurse that she felt the L&D Nurse had practiced according to Rule 217.11, specifically refusing an assignment for which she was not educationally or experientially prepared. The Consultant also wrote that she did not believe that this was a situation in which Safe Harbor should have been invoked, since the L&D Nurse had no experience with cardiac patients, drugs, treatments or monitoring strips. The following morning, very early, the L&D Nurse printed a copy of Rule 217.11 and underlined the sections that state a nurse is not to give nor accept an assignment for which the Nurse is not educationally or experientially prepared. She also printed a copy of the email from the Board Consultant. She slipped both of these documents under the door of the Unit Manager, who was not at work yet. On Thursday, the L&D Nurse went to the hospital as instructed. She was met by her Unit Manager and an HR Representative and told she was terminated. She was informed by the Unit Manager that she had been trying to figure a way to send the L&D Nurse’s name to the Board for abandonment of patients, but the situation simply did not fit the definition of abandonment. So, after 12 years of loyalty to her hospital, she was discharged. She obviously was very upset and, after much thought, decided that she was going to sue her employer—not only to stand up for herself, but also, in her mind, for all nurses. The case literally settled on the court house steps a few hours before the jury was to be picked. Though the hospital fought the lawsuit, I think the main reason the hospital settled was because, by slipping the documents under the Unit Manager’s door that Tuesday morning, the facts of the case now supported a Whistle Blower cause of action. The hospital was aware that the L&D Nurse had whistle blown to the Board as to their allegedly unlawful act- the unlawful act being the assignment in violation of the Nursing Practice Act and Board Rule. Slide 6: Peer Review Meeting Purposes 1. Incident-Based Peer Review • Nurse is being investigated [217.19] 2. Safe Harbor Peer Review • Nurse is requesting SH [303.005] Common rights: a) appear before the committee b) ask/be asked questions c) make verbal or written statement st To review, there are two reasons for the Peer Review Committee to meet. The 1 reason is for Incident Based Peer Review- when the nurse is the Respondent and is being investigated for a practice or a professional character issue. The 2nd reason is for Safe Harbor Peer Review- when it is the NURSE who requests the Peer Review Committee to meet. Therefore, the Nurse does not have the same rights in place in Safe Harbor Peer Review as he or she has in Incident Based Peer Review. The rights that are common to both types of Peer Review for the Nurse are the right to appear before the Committee, the right to ask and be asked questions and the right to make a verbal or written statement. I consider Safe Harbor to be a positive piece of legislation for nurses. I continue to be astounded that it has been so poorly understood. And even used as a source of conflict and coercion against the nurse. It is your responsibility to educate yourself on the use of Safe Harbor and consider invoking it when appropriate. Perhaps if more nurses used Safe Harbor, there would be less names of disciplined nurses each quarter in the BON Bulletin! 2. Staffing (Week 3) 7 questions Readings: □ BON perspective on staffing ratios Staffing Ratios Is there a law regarding how many patients (nurse: patient ratio) a nurse can be assigned to care for in Texas? The Texas Board of Nursing (BON) has no authority over workplace or employment issues, such as staffing ratios. The Nursing Practice Act (NPA) and Board Rules and Regulations are written broadly to apply to nursing practice in any setting. In particular, you should familiarize yourself... with the main rule applied to nursing practice, Rule 217.11, Standards of Nursing Practice. This rule provides the minimum standards nurses must meet in accepting any assignment, including floating, working short staffed, and other practice situations. • Standard 217.11(1) (B) requires the nurse to maintain a safe environment for the patient. This requirement supersedes any agency policy or physician order. • Standard 217.11(1) (T) holds the nurse accountable to accept only those assignments that are within the nurse's education, training, and experience, as well as his or her physical and emotional ability. If a licensed nurse accepts an assignment, he or she is responsible for the care delivered. • Standard 217.11(1) (S) applies to charge nurses or nurses who are in management positions. This standard is the "companion" standard to (1) (T), as it requires the nurse who is supervising other nurses to "make assignments" that take into account the educational preparation, knowledge, skills, and physical, mental, and emotional abilities of the nurses for whom the supervisor is administratively responsible. This does not mean other nurses are working under the supervisor's license, or that the supervisor is responsible for every aspect of care delivered by other staff nurses. Assignments made to other licensed nurses do require forethought and adequate supervision. • Standard 217.11(1) (U) holds supervisors responsible to oversee the nursing care provided by others for whom the supervisor is professionally responsible, from a licensure standpoint, the responsibility for overall patient care is the responsibility of the staff nurse accepting the assignment. During the 2009, 81st Legislative Session, SB 476 was enacted and changed the Health and Safety Code. If you practice in a hospital, you may wish to contact the Department of State Health Services (DSHS) - Health Facility Program at or You may also wish to contact various nursing specialty organizations, such as the Texas Nurses Association at or . While the Board cannot address employment issues, specialty nursing organizations exist to serve their members and may be able to provide you with additional guidance. The Texas Hospital Association, or , has developed a Nurse Staffing Law Toolkit that may provide nurses and hospitals with additional resource information. If you believe, you are being asked to accept an assignment that would cause you to violate the NPA or rules, especially any of the standards of practice in Rule 217.11, you may wish to review the NPA Section 301.352 Protection for Refusal to Engage in Certain Conduct. If your facility or employer routinely utilizes at least 10 nurses, 5 of which are RNs, you may wish to consider invoking Safe Harbor. While the BON does not have authority over workplace issues, such as determining nurse: patient ratios, there are protections in both the NPA and the Safe Harbor Rule 217.20 for a nurse who declares Safe Harbor in good faith. If adverse employment action was taken against a nurse, then the nurse may choose to seek private legal counsel. Rule 217.20 (e) outlines the requirements the nurse must meet in order to secure the protections, what the protections are, and where they are listed in the Texas Occupations Code, Section 303.005. □ Texas Staffing Rules and Statutes from TNA (Nurse Staffing Facts ONLY) FACT: The 2009 law gives nurses even more influence in staffing decisions. • Direct care nurses throughout Texas have an even stronger voice in setting appropriate nurse-to-patient staffing levels at their hospitals. • The law enhances existing nurse staffing regulations and strengthens the voice of Texas nurses on staffing matters in several ways. • It adds a legal requirement for hospital governing boards to adopt a nurse staffing policy that considers staffing guidelines set forth by professional nursing organizations. • The role and status of the nurse staffing committee is elevated to a standing committee that reports directly to the hospital board. • The nurse staffing committee is to be comprised of at least 60% registered nurses who provide direct patient care at least 50% of the time and that are selected by their nurse peers who also provide direct patient care at least 50% of the time. • The nurse staffing committee is responsible for identifying the nurse- sensitive outcome measures to be used in evaluating the staffing plan. • The committee will evaluate and report on the staffing plan’s effectiveness at least semiannually to the hospital board. • Hospitals are required to report annually certain data about their nurse staffing plan to the Texas Department of State Health Services (TDSHS). FACT: The law also prohibits mandatory overtime. • The Law includes a prohibition on mandatory overtime in hospitals except in emergency circumstances, such as a natural disaster. FACT: Direct care nurses know best what their patients need. • Patient outcomes are linked directly to appropriate staffing, so it makes good sense for nurses to have the opportunity to influence staffing. • Nurse staffing committees allow nurses to influence appropriate staffing levels at each hospital in Texas based on the unique needs of each patient, the specific expertise and experience of nurses on each shift, and the particular characteristics of each hospital. FACT: Collaboration works. Texas has led the Nation in addressing nurse staffing in hospitals, thanks to a collaborative approach that brings nurses and other stakeholders together to best serve patients. • Texas has been at the forefront of nurse staffing in hospitals. • For more than 100 years, TNA has advanced the nursing profession and improved nurses’ practice environments and patient care by working collaboratively with other stakeholders to effect real, positive change. • Members of the TNA are Texas registered nurses who advocate for patients, nurses and the nursing profession, and quality care for all Texans. TNA hosts the Nursing Legislative Agenda Coalition (NLAC). Representing more than 20 nursing organizations in Texas, the NLAC identifies significant nursing and health care related issues that the Texas Legislature should address. Since NLAC represents all practice settings and segments of nursing, it serves as the body that builds a unified position on the issues important to nurses and their patients. □ Nurse Staffing Overview Nurse Staffing Registered nurses have long acknowledged and continue to emphasize that staffing issues are an ongoing concern, one that influences the safety of both the patient and the nurse. There is a strong relationship between adequate nurse-to- patient ratios and safe patient outcomes. Rising patient acuity and shortened hospital stays has contributed to challenges. Finding an optimal nurse-to-patient ratio has been a national challenge. However, rising patient acuity and shortened hospital stays have contributed to recent challenges. Ensuring adequate staffing levels has been shown to: • Reduce medical and medication errors • Decrease patient complications • Decrease mortality • Improve patient satisfaction, • Reduce nurse fatigue • Decrease nurse burnout • Improve nurse retention and job satisfaction Health care leaders have an opportunity to create innovative strategies through a collaborative effort and to develop solutions that will build a safer environment for patients and registered nurses. Staffing solutions require leadership support and recognition to assure an appropriate number and skill mix of registered nurses who are able to deliver safe quality patient care. An optimal staffing model requires an approach that recognizes unique patient care settings during specific times of day and must assess: • Patient Acuity • Unlicensed assistive personnel • Skills, education, and training within specific settings Implications for practice: Optimal staffing is essential in order to provide optimal patient care. Innovative and collaborative strategies that focus on developing long-term solutions will improve the quality of patient care outcomes. □ State Safe Staffing Legislation Identifying and maintaining the appropriate number and mix of nursing staff is critical to the delivery of quality patient care. Numerous studies reveal an association between higher levels of experienced RN staffing land lower rates of adverse patient outcomes. Learn more » When health care employers fail to recognize the association between RN staffing and patient outcomes, laws and regulations become necessary. A Federal regulation has been in place for some time, 42 Code of Federal Regulations (42CFR 482.23(b) which requires hospitals certified to participate in Medicare to "have adequatenumbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed". This nebulous language and the continued failure of Congress to enact a federal law. The Registered Nurse Staffing Act has left it to the states to ensure that staffing is appropriate to meet patients' needs safely. State staffing laws tend to fall into one of three general approaches: • The first is to require hospitals to have a nurse driven staffing committee which create staffing plans that reflect the needs of the patient population and match the skills and experience of the staff. • The second approach is for legislators to mandate specific nurse to patient ratios in legislation or regulation. • A third approach is that of requiring facilities to disclose staffing levels to the public and /or a regulatory body. The American Nurses Association (ANA) supports a legislative model in which nurses are empowered to create staffing plans specific to each unit. This approach aides in establishing staffing levels that are flexible and account for changes; including intensity of patient's needs, the number of admissions, discharges and transfers during a shift, level of experience of nursing staff, layout of the unit, and availability of resources (ancillary staff, technology etc.). Establishing minimum upwardly adjustable staffing levels is statute may also aide the committee in achieving safe and appropriate staffing plans. States with Staffing Laws 13 states currently addressed nurse staffing in hospitals in law / regulations: CA, CT, IL, MN, NV, NJ, NY, OH, OR, RI, TX, VT, and WA. • 7 states require hospitals to have staffing committees responsible for plans and staffing policy – CT, IL, NV, OH, OR, TX, WA. • CA is the only state stipulates that in law and regulations a required minimum nurse to patient ratios to be maintained at all times by unit. MA passed a law specific to ICU requiring a 1:1 or 1:2 nurse to patient ratio depending on stability of the paitent. • MN requires a CNO or designee develop a core staffing plan with input from others. the requirments are similar to Joint Commission standards. • 5 states require some form of disclosure and / or public reporting – IL, NJ, NY, RI, VT Other limited efforts...... • NM (2012) charged specific stakeholder groups to recommended staffing standards to the legislature; the department of health is to collect information about the hospitals that adopt standards and report the cost of implementing an oversight program. • NC (2009) requested a study in the use of mandatory overtime as a staffing tool. No subsequent action taken. • DC and ME (2004) – passed legislation; later amended from original intent; staffing mandate removed. Videos: □ Hospital Nurse Staffing Rules (w/ accompanying slide handout) (24 Minutes) Texas Hospital Nurse Staffing Rules and Staffing Statute of 2009 Current Types of Staffing Regulations in US • Hospital Staffing Committee – Committee recommends plan for each unit in hospital – Most committees 50% direct care nurses – Look at acuity, staffing mix, technology to set plan • Mandated Patient/Nurse Ratios – Mandates minimum ratios for every unit state wide 24 hrs/day by type of unit • Some form of disclosure &/or public reporting History of Staffing Regulations in US (as of Fall 10) • – 15 states implemented staffing regulations – 7 states hospitals staffing committees • CT, IL, NV, OH, OR, TX, WA – 1 state mandated ratios law passed 1999, into effect 2003 • CA – 5 states some form of disclosure & / or public reporting • IL,NJ,NY,RI,VT. TX Nurse Staffing Rules Originally Adopted – TDH 2002 (now DSHS) • 2001 TNA & THA submitted agreed upon rules – implemented 2002 • Purpose – improve workplace environment • Goal – retain RNs & improve pt care • Texas 1st in nation to implement staffing regulations TDSHS, Administrative Code, Title 25, Chapter 133, Hospital Licensing Statute 2009 - Hospital Safe Staffing Law, Health & Safety Code, Chapter 257 Rules Created 2002 Retained • Each hospital to set staffing levels for each unit in house • Each hospital have staffing committee • Staffing levels dependent on: – Type of pt. – care needs – Acuity of pt. – Staff experience & mix – Environment - Layout of the unit/Technology /etc. Rules Created 2002 Retained CNO - Be an RN with masters or equivalent ..or have a written plan of progression Exemptions: hospitals which either: • a)have 100 or fewer beds & in counties with less than 50,000 population; or • b)are certified as critical access hospitals Rules Created 2002 Retained CNO – Report directly to CEO CNO participate with leadership in performance improvement activities Rules Created 2002 Retained • Policies require orientation to all temp or permanent assignments • Orientation & competency documented • Nursing assignments congruent with competency Rules Created 2002 Retained Plan must consider outcomes & indicators At least 1 from each of 3 types Type 1: that are nurse sensitive pt outcomes: • patient falls, adverse drug rxts, infection rates, length of stay, etc. Type 2: Operational outcomes: • work related injury, vacancy & turnover rates, nursing care hours per patient day Type 3: Patient complaints related to staffing levels Rules Created 2002 Retained Nurse Safe Harbor Peer Review ..use of process to address staffing concerns Rules Created 2002 Retained Staffing Rule/ Whistleblower • A hospital cannot terminate, or discipline an employee if reports violation in good faith Rules Created 2002 Retained Harassment & Abuse Shall adopt, implement & enforce written policy to ID & deal with: Verbal & physical abuse/ harassment by: • Employee, • Contracted personnel • Health care provider with clinical privileges Why the Statute 2009? • Research Supports: • Adequate staffing directly related to + pt. outcomes • Nurse satisfaction increased by adequate staffing • Nurse satisfaction & pt. safety adversely affected when nurses work excessive hours • Hosp. & Nurses desire pt safety initiatives & healthy environment Why the Statute 2009? • Many nurses not aware of Staffing Rules • Calls to TNA of nurses reporting: – Hospitals not following rules – Unsafe staffing levels – Afraid of retaliation Staffing Rules There shall be supervisory & staff personnel to provide immediate availability of RN for bedside care of any patient Staffing Rules Hospital shall adopt, implement & enforce written staffing policy Staffing Rules • Nurse Staffing Committee – a Standing Committee of Hospital reporting directly to hospital board Staffing Rules • Staffing Committee makeup: – 60% direct care RNs (RNs giving 50% pt care) – Committee RNs selected by peers – CNO – Members represent types of nsg service Role of Staffing Committee • Meet at least 4 x/yr • Create recommended staffing plan • Paid for meetings • Meeting not during regular duty time • Review, assess, & responds to concerns from staff nurses Role of Staffing Committee • Evaluate official actual staffing levels 2x/yr – Determine pt outcomes to use as measurement – Determine effectiveness & variations – Consider pt needs, nsg sensitive quality indicators, evidence-based standards • Report eval outcomes to hospital board 2x/yr Official Hospital Staffing Plans Must: • Nurse Staffing Committee’s plan must be given “significant consideration” • Be consistent with: licensing board standards & codes of ethics of nat’l nursing orgs Must: • Be used to set Nursing staffing budget • Protect the nurse giving care concerns to committee from retaliation Must: • Be meet evidence-based safe practice • Be flexible to meet pt changing needs • Be readily available to staff Hospital Board Responsibility • Report to DSHS yearly • Report to include if: – 1. Adopted Nsg staffing policy – 2. Established staffing committee to meet statue requirements – 3. Committee evaluated Official Plan and reported to Board 2x/yr – 4. What Nsg sensitive outcomes the committee adopted for eval. Staffing Plan/Mandatory Overtime • Address Mandatory Overtime: • *Mandatory Overtime= time required to work when not scheduled Staffing Rule/Mandatory Overtime • Hospitals MAY NOT require nurses to work overtime • Voluntary Overtime OK • Required On-Call - not a substitute • Can not retaliate if nurse refuses to work Staffing Rule/Mandatory Overtime • Exceptions for Mandatory Overtime – Disaster – Declaration of emergency – Event that: doesn't occur regularly, could not prudently be anticipated, increases need for safe pt care, • Nurse actively involved in procedure Your Role as Nurse • Explore how committee works in your agency • Get to know the nurse leaders in agency • Keep Healthcare Policy Advocate in mind 3. Unions (Week 3) 2 questions Readings: □ Handout: Facts of Unionization Toolkit (12 page document on blackboard) Videos: □ No video – but PPT handout on Unions NURSING UNIONS IN TEXAS Union Basics - Definitions  Union – Organization of workers dedicated to protect the interest & improve wages hours & work conditions  Bargaining unit – group represented by a union  Majority of workers in bargaining unit vote for union  Dues – members pay to cover union cost  Collective bargaining agreement – union negotiates with employer for wages, work conditions, etc  Arbitration – when agreement broken Union Basics - Laws  Federal Laws  1935 National Labor Relations Act  To encourage good relations between workers & employers  Rt to join unions & engage in collective bargaining  1947 Labor Management Relations Act  Taft-Hartley Act  Gave government firmer control over labor disputes Union Basics – Law (cont)  Right to Work Law 1940 – Prohibit paying union dues a condition of employment  1993 Texas Right-to-Work Act  Right to bargain with employer  individual or group  Can not require membership  Withholding union dues void w/o consent  Can not deny employment Union Basics  Who can belong to union?  “workers” only - No one in any kind of management position  If concern or problem in work facility?  Go to union rep to handle Union Basics  How are raises given?  According to agreement  --- no merit raises.  Raises are across the board Nursing Union Activity in Texas  History  1979 TNA  Union activity since 1979  CNA activity in Texas  Tenet hospitals – 2008 Cypress Fairbanks  HCA Hospitals – 2010 five Hospitals South TX Effects of Unionization  Why would hospital nurses want to unionize?  Activities of hospital management  Employee Free Choice Act  Secret ballot vs. open ballot  Effect of unions on salaries  Effect of unions collaboration  Fixed staffing ratios vs. unit based staffing plan 4. Malpractice (Week 4) 15 questions Readings: □ Position Statement 15.14 Duty of a Nurse in Any Practice Setting In a time when cost consciousness and a drive for increasing productivity have brought about the reorganization and restructuring of health care delivery systems, the effects of these new delivery systems on the safety of clients/patients have placed a greater burden on the licensed vocational nurse (LVN) and the registered professional nurse (RN) to consider the meaning of licensure and assurance of quality care that it provides. In the interest of fulfilling its mission to protect the health, safety, and welfare of the people of Texas through the regulation of nurses, the Board of Nursing (BON), through the Nursing Practice Act and Board Rules, emphasizes the nurse’s responsibility and duty to the client/patient to provide safe, effective nursing care. Specifically, the following portions of the Board Rules and supporting documents underscore the duty and responsibilities of the LVN and/or the RN to the client/patient: • The Standards of Nursing Practice differentiate the roles of the LVN and the RN in accepting nursing care assignments, assuring a safe environment for patients, and obtaining instruction and supervision as needed (22 TAC § 217.11); and • In Lunsford v. Board of Nurse Examiners, 648 S.W. 2d 391 (Tex. App.--Austin, 1983), the court in affirming the disciplinary action of the Board, held that a nurse has a duty to the patient which cannot be superseded by hospital policy or physician's order. This landmark case involved a gentleman who arrived to a rural hospital via private vehicle. The gentleman was experiencing severe chest pain, nausea, and sweating—all hallmark symptoms of myocardial infarction (heart attack). Nurse Lunsford was summoned to the ER waiting room by this gentleman’s friend. Upon seeing the acute distress the man was experiencing and hearing his symptoms, she instructed his friend to drive the man to the nearest facility equipped to handle heart attack victims. This facility was 24 miles away. The man succumbed to the heart attack 5 miles away from the small hospital. When the Board sought to sanction the nurse’s license, the nurse maintained that the ER physician (who never saw the man) told her the man needed to be transported to the larger facility. The facility policy was also to transfer patients experiencing heart attacks (via ambulance) to the larger facility that was equipped to provide the broad range of therapies that might be needed. The court sided with the BON and agreed that the nurse had the knowledge, skills and abilities to recognize the life-threatening nature of the man’s symptoms. Because of this knowledge, the court maintained that it was the nurse’s duty to act in the best interest of the client by assessing the man, taking measures to stabilize him and to prevent complications, and communicating his condition to other staff (such as the MD) in order to enlist appropriate medical care. • The Board’s Disciplinary Sanction Policies discuss expectations of all nurses regarding behaviors that are consistent with the Board’s rules on Good Professional Character, 22 TAC §§213.27-213.29. These policies explain the client’s vulnerability and the nurse’s “power” differential over the client by virtue of the client’s status (with regard to age, illness, mental infirmity, etc.) and by the nature of the nurse:client relationship (where the client typically defers decisions to the nurse, and relies on the nurse to protect the client from harm). • The delegation rules guide the RN in delegation of tasks to unlicensed assisti