If you find yourself in a situation that you believe creates unsafe conditions for patients or for you,
complete the Nurse Staffing Concern Form.

By completing the staffing Concern Form, you are helping to make the problem known to management, which creates an opportunity for the problem to be addressed. Additionally, you are documenting the facts, which may be helpful to you later if there is a negative outcome due to the concerns that you identify.

Types of Situations Where You Should Complete a Staffing Concern Form:

• Charge nurse is unable to perform charge nurse duties, secondary to increased patient care assignment
• Inadequate nurse to patient ratios for patient acuity based on your clinical judgment
• Insufficient support staff requires you to assume additional duties
• You are not trained or experienced in the area assigned
• You have not been oriented to this unit / case load
• Patient care equipment missing or unusable
• Necessary equipment is not available (e.g.: supplies, IVs, medication availability)
• You are not trained or experienced to use equipment in assigned area
• System failure (e.g.: computer, phone, pyxis, call system)
• An assignment poses a serious threat to your health and safety
• An assignment poses a serious threat to the health and safety of a patient under your direct care
• Forced / Mandatory Overtime
• Missed breaks