Question: I am a Neonatal ICU RN and work at a very large hospital. I have not cared for adults or worked in other clinical practice settings for over 4 years. What are my rights when it comes to floating to different clinical units (adults, pediatric, ER, etc.)? The census in my department has been very low for a while and many times the extra nurses that are scheduled are floated to the Pediatric units and now Adult units. I did this once last year and had a really bad experience, and I left fearing for my license. I have heard that I could call Safe Harbor, but many people including myself don't know much about it. Please help!
Answer: The Nursing Practice Act (NPA) and Board rules are written broadly to apply to nursing practice in any setting. The Board of Nursing (BON) has no authority over workplace policies, such as floating or staffing ratios. Nurses are required to "know and conform" with the NPA and Board Rules, both of which have the force of law for licensed nurses (LVN, RN, or RN with Advanced Practice authorization in a specific role and specialty). You should familiarize yourself with Rule 217.11, Standards of Nursing Practice , as these would be your area of concern in a floating or other potentially unsafe practice situation.
- Standard (1) (B) requires the nurse to maintain a safe environment for the patient. This requirement supersedes any agency policy or physician order; also see Position Statement 15.14, Duty of a Nurse in Any Practice Setting.
- Standard (1) (P), in situations where nurses are floating, working double or extra shifts, taking charge duties, or working short-staffed, clear communication between staff and supervisors is essential to manage patient care and decrease conflict in the work setting. A nurse may also seek opportunities in his or her practice setting to become involved with committees or other facility-based efforts in developing staffing strategies that comply with the nurse’s scope of practice and that balance the needs of the facility with the requirements for safe patient care.
- 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.
- Standard (1) (T) holds the nurse accountable to accept only those assignments that are within the nurse’s education, training, or experience, as well as his or her physical and emotional ability. If you accept an assignment, you are responsible for your nursing actions.
- Standard 217.11(1) (U) holds supervisors responsible to oversee the nursing care provided by others for whom the supervisor is professionally responsible.
If you feel 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 will want to refer to Section 301.352 of the NPA which addresses the nurse's right to refuse an assignment. The Request for Peer Review Determination or Safe Harbor originates from this statute. Safe Harbor protects you from potential action against your nursing license and retaliatory action from your employer when the procedure is correctly followed. The idea behind Safe Harbor is that a group of nursing peers examines the assignment the nurse was asked to accept and determines whether the nurse was being asked to accept an assignment that was unsafe and or outside of his or her knowledge, skills, and physical or emotional abilities. Safe Harbor is invoked at the time you are asked to engage in an activity or an assignment that you believe is not safe for patients. Remember you cannot invoke Safe Harbor after a patient has been hurt or after the shift is over and done. Patient safety as the focus, the Peer Review Committee can be a catalyst for positive changes, resulting in improved staffing systems. The Safe Harbor Rule 217.20, Safe Harbor forms and a Frequently Asked Question (FAQ) are resources available on the Board’s website that will assist you if you choose to invoke Safe Harbor.
As you already have concerns about the staffing pattern or floating on a daily basis and the potential for patient harm and jeopardizing your license, you may wish to consider speaking with your nurse manager before an untoward event occurs. Though it would not be invoking Safe Harbor, you might find it helpful to utilize some of the information requested on the safe harbor form to explain why you have concerns about floating to areas outside of your clinical expertise and or competence. Whether submitted as a clinical concern or as a request for Safe Harbor Peer Review, Board staff recommends you try to think of and submit some possible ideas for solutions that promote flexible staffing without jeopardizing patient safety or nursing licenses, such as "functional" floating, floating within cross-trained groups, etc.
Safe Harbor Peer Review is an internal process, between you and your employer. You should give a copy of the Safe Harbor form to your nurse manager and keep a copy for yourself, Rule 217.20(d)(3), for future reference. The BON does not get involved with Safe Harbor Peer Review, but may be involved after-the-fact if peer review is not conducted in good faith. You may wish to seek your own legal counsel for advice on employment issues. The BON cannot provide legal advice, and has no authority in civil matters.
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 1-888-973-0022 or http://www.dshs.state.tx.us/hfp/default.shtm about the regulations for the official nurse staffing policies and plans that took effect on September 1, 2009.
You may also wish to contact various nursing specialty organizations, such as the Texas Nurses Association at 512-452-0645 or www.texasnurses.org. 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 at www.tha.org or 512-465-1000 has developed a Nurse Staffing Law Toolkit that may provide nurses and hospitals with additional resource information.
Revised October 2009