Name of your hospital

Implementation of New Law

Composition of nurse staffing committee

Do you Agree or Disagree with the following statement: Our nurse staffing committee is composed of at least ½ registered nurses providing direct patient care

AgreeDisagreeOther

Do you want to add a comment?

Do you Agree or Disagree with the following statement: Staff nurse members of the nurse staffing committee are selected according to the collective bargaining agreement for my hospital

AgreeDisagreeOther

How are nurses selected?

By peersBy administrationI don’t know

Do you Agree or Disagree with the following statement: The nurse staffing committee meets often

AgreeDisagreeOther

Development and adoption of your hospital’s nurse staffing plan

Do you Agree or Disagree with the following statement:

The annual patient care unit and shift staffingplan is primarily developed by the NSC

AgreeDisagreeOther

The following factors were considered in the development of the nurse staffing plan

Do you Agree or Disagree with the following statements:

Census, including total numbers of patients on the unit on each shift were considered in the development of the nurse staffing plan

AgreeDisagreeOther

Activity such as patient discharges, admissions, and transfers were considered in the development of the nurse staffing plan

AgreeDisagreeOther

Level of intensity of all patients and nature of the care to be delivered on each shift were considered in the development of the nurse staffing plan

AgreeDisagreeOther

Skill mix of staff were considered in the development of the nurse staffing plan

AgreeDisagreeOther

Level of experience and specialty certification or training of nursing personnel providing care were considered in the development of the nurse staffing plan

AgreeDisagreeOther

The need for specialized or intensive equipment were considered in the development of the nurse staffing plan

AgreeDisagreeOther

Availability of other personnel supporting nursing services on the unit were considered in the development of the nurse staffing plan

AgreeDisagreeOther

Strategies to enable registered nurses to take meal and rest breaks as required by law or collective bargaining agreement were considered in the development of the nurse staffing plan

AgreeDisagreeOther

What strategy is in place?

Float RNBreak RNBreak BuddyOther

If you are being forced to miss Meal and Rest Breaks or use a "Break Buddy" in order to take your break then your employer could be breaking the law. A Union Rep may want to contact you to hear more details about your situation and be sure you have the support and coverage as outlined in the law and by our Union contract.

Name

First NameLast Name

Email

example@example.com

Phone Number

Area CodePhone Number

The nurse staffing plan is posted with actual staffing levels (nurses and relevant clinical staff) for each shift in a public area on each patient care unit?

AgreeDisagreeOther

Implementation and Monitoring of the Nurse Staffing Plan

Do you Agree or Disagree with the following statements:

The NSC has a point person responsible for collecting data regarding nurse staffing complaints

AgreeDisagreeOther

The NSC has reviewed data regarding nurse staffing complaints

AgreeDisagreeOther

The NSC has a process to examine and respond to nurse staffing complaints

AgreeDisagreeOther

If you have submitted a CSI complaint have you received a response back from the Nurse Staffing Committee?

AgreeDisagreeOther

The NSC has a process to track patterns of unresolved complaints

AgreeDisagreeOther

The NSC is or will be scheduled to review the plan within 6 months of adoption.

AgreeDisagreeOther

Do you have any additional comments about the NSC?

Describe one thing you are most proud of regarding your NSC

Describe one thing that was (or has been) most challenging for your NSC

Describe one thing about your NSC that you hope is improved in the coming year

Nurse Staffing Committee RN Survey

Implementation of New Law

Composition of nurse staffing committee

Development and adoption of your hospital’s nurse staffing plan

The following factors were considered in the development of the nurse staffing plan

Implementation and Monitoring of the Nurse Staffing Plan