• Limits of Safe Practice Assessment

  • This assessment should be done in any circumstance where in the professional judgement of the nurse, or nursing team, there is an inability to provide appropriate care for one or more health consumer/s. This includes but is not limited by the presence of one or more factors affecting safe practice in the Limits of Safe Practice Assessment.

    Privacy Act 2020

    The personal and health and safety information collected on this form may be used to facilitate safer staffing in the workplace.

    This statement does not replace, and should be read in conjunction with, the privacy statements on the NZNO online joining form.

    You are protected when raising a health and safety matter

    It is illegal for the PCBU (i.e. your employer or their representative) to take discriminatory action against you or other workers for completing this assessment. Under the Health and Safety at Work Act 2015 you have protections from such conduct.

    Please complete both Sections of this form

    • Section 1 captures the formal assessment of the situation. On completion you will be sent a PDF file and an Edit link so you can return to complete Section 2.
    • Section 2 captures what happens after your senior RN/MW is informed of the situation. On completion you will be sent a PDF link for the full report and an Edit link for any further updating.

    Your NZNO Delegate and your Health and Safety Representative can review these Assessments and follow up with your senior RN/MW. You can also liaise with your local NZNO Organiser if further assistance and/or escalation is required.

    If you have any questions or concerns, please contact us at nurses@nzno.org.nz.

  • Section 1

  • Date of assessment*
     - -
  • Submitter authority (select items which apply)*
  • Do you use TrendCare in your work area?*
  • Local actions taken before informing senior RN/MW
  • Local actions taken before informing senior RN/MW

  • Factors affecting safe practice (may include)

  • DO NOT include information which identifies an individual health consumer e.g. Name or NHI

  • 1. Variance Indicator System (VIS) level is in an adverse colour status*
  • 2. Care is reduced to provision of life preserving services*
  • 3. Clinical emergency not manageable with existing workers/support*
  • 4. Inability to provide time-critical cares and assessments*
  • 5. Absence of appropriate cultural support is significantly impacting upon wellbeing of the health consumer and/or whanau*
  • 6. Worker and/or other person at risk of physical/mental harm due to unsafe behaviour of a health consumer; the control measures in place are inadequate*
  • 7. Inability to monitor a health consumer with behaviour of concern who requires constant close supervision*
  • 8. Physical/mental harm has occurred or is occurring to a worker, health consumer or other person*
  • 9. Worker and/or other person at risk of physical/mental harm due to unsafe behaviour of the health consumer’s whanau or other visitor; the control measures in place are inadequate*
  • 10. Care rationing is occurring*
  • 11. Cares and assessments are unduly delayed*
  • 12. The worker skill mix is unsuitable*
  • 13. There is insufficient essential equipment or supplies*
  • 14. Health consumer dignity is compromised, e.g. personal and hygiene cares not attended to in a timely manner*
  • 15. Worker/s have been unable to take meal and/or rest breaks, affecting their ability to provide care safely*
  • 16. The workplace environment being used is not fit-for-purpose for the delivery of safe and competent care e.g. a health consumer being treated on a stretcher in a corridor*
  • 17. Other roles that work with and support the nursing team are reduced to care rationing or unavailable e.g. Medical, Allied Health, other non-clinical support*

  • Senior RN/MW informed that worker/s are at the Limits of Safe Practice

  • Declaration

  • This report is completed on behalf of the work team in the identified Ward/Service/Unit.

    I declare that this Limits of Safe Practice assessment has been completed in good faith using professional judgement, and that to the best of my knowledge and ability, the information provided is as true and correct as was possible to determine under the circumstances of an acute staffing shortage situation.

  • Click Submit to receive an email which contains:

    1. A printable PDF of this Assessment (includes Section 1 only) which you can give to the senior RN/MW who reviews the situation.
    2. An edit link to come back and complete Section 2 of this Assessment.

    It is important that you return to complete Section 2. This Assessment can only be followed up by NZNO if both sections are completed.

    Please remember to come back and complete Section 2.

    • Review section 

    • Section 2

    • Senior RN/MW review to validate whether Acute Staffing Shortage situation exists

    • Did the Senior RN/MW review take place?*

    • Outcome after senior RN/MW notified that an Acute Staffing Shortage situation exists

    • Were the issues resolved?*
    • Was a Safe Staffing Next Shift Assessment completed on the shift prior to this one?*

    • Mandatory reporting

    • Has a fellow worker been harmed?  If yes, please complete a Work Accident Report.

    • Has a health consumer been harmed?  If yes, make sure this is documented in their Clinical Record.

    • Click the Submit button now to receive an email which contains:

      1. A download link to a PDF of the Assessment for your records (includes both sections of the form)
      2. A link which allows you to edit the Assessment after submission, for example to add an Incident Report number.

      A copy of this form will be emailed to safestaffing@nzno.org.nz. The information will be reviewed by your local NZNO Organiser and stored for use as needed with the escalation pathway process.

      Thank you very much for taking the time to complete this Assessment. You're helping to make your workplace safer for yourself and your colleagues.

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